Reproductive Surgery

Tuboplasty

Nolan W et al., 2026 · Textbook of Minimally Invasive Gynecologic Surgery

Vasectomy Reversal Provides Symptomatic Relief in Patients With Postvasectomy Pain Syndrome: A Systematic Review

Lahiji R et al., 2026 · Urology practice

Postvasectomy pain syndrome (PVPS) is a poorly understood, chronic condition affecting up to 5% of men post vasectomy. With limited evidence guiding its management, vasectomy reversal (VR) has been referenced as a potential treatment modality. This systematic review evaluates the current literature on the efficacy of VR in relieving PVPS symptoms. A systematic search was conducted across PubMed, ScienceDirect, SCOPUS, and Web of Science databases in accordance with Preferred Peporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Eligible studies included case series and clinical reports from the last 15 years that assessed pain outcomes after VR in men diagnosed with PVPS. Primary outcomes included pain resolution or reduction postoperatively, measured through visual analogue pain scores or patient-reported outcomes. Five studies involving 123 patients were included, encompassing vasovasostomy, vasoepididymostomy, and robotic-assisted techniques. All studies reported symptomatic improvement after VR, with pain score reductions ranging from 60% to 83%. While 2 studies used validated pain scoring systems before intervention and post intervention, the remaining studies reported other subjective or percentage-based improvements. Across all studies, VR was associated with high rates of patient satisfaction and willingness to undergo the procedure again. VR seems to offer meaningful pain relief in patients suffering from PVPS. However, further high-quality prospective studies and randomized controlled trials are needed to concretely establish its efficacy, compare it with alternative treatments, and develop standardized treatment algorithms.

"Uterine closure after cesarean delivery: surgical technique, biological rationale, and clinical implications."

Bujold E et al., 2026 · American Journal of Obstetrics and Gynecology · Open Access

Normal uterine function depends on cyclical regeneration and the capacity to sustain pregnancy. A cesarean incision represents an injury to this remarkable organ. Although the uterus possesses exceptional healing potential, cesarean delivery increases the risk of secondary infertility, pelvic pain, uterine rupture, and abnormal placentation in subsequent pregnancies. The two most important determinants of successful hysterotomy healing after cesarean delivery are the location of the incision and the surgical technique used for closure. The anatomic site of entry-whether the corpus, lower uterine segment, or cervix-defines the tissue composition, vascularity, and contractility at the wound margins, which in turn influence how the scar remodels and withstands subsequent pregnancies. Surgical technique is also important. A robust body of experimental and clinical evidence demonstrates that restoring anatomic integrity by reapproximating uterine layers while excluding the endometrium produces stronger scars and reduces late complications. The rationale for excluding the endometrium is to prevent displacement of endometrial tissue into the myometrium and to avoid mucosal tearing against a foreign body (i.e. suture material), both of which predispose to defective healing. When the endometrium is incorporated, healing is often impaired, leading to niches or isthmoceles, adenomyosis, and endometriosis at the scar site. Over time, these defects have been recognized as contributors to abnormal bleeding, pelvic pain, infertility, uterine rupture, and placenta accreta spectrum disorders. Despite this evidence, single-layer closures that incorporate endometrium became widely adopted because of their speed and simplicity, while their long-term sequels were initially underappreciated. This has prompted renewed scrutiny of closure techniques, including comparisons of single-layer vs double-layer closure, locking vs nonlocking sutures, type of sutures, and the direction of suture. Collectively, the data show that optimal closure respects uterine anatomy, restores the natural alignment of tissues, and achieves hemostasis without compromising perfusion or strangulating tissues. Building on these principles, we herein describe a refined 3-layer closure. The first layer approximates decidua and junctional myometrium while excluding surface endometrium to prevent tissue entrapment and bacterial contamination. The second layer restores anatomic wall integrity by reapproximating the bulk of the myometrium, thereby reinforcing strength and distributing tension across the scar. The third layer reapproximates superficial myometrium and serosa, smoothing the uterine surface and reducing adhesions. This technique is not simply a return to traditional double-layer methods or an extension of single-layer practice, but rather a refinement that integrates lessons from visceral surgery and contemporary obstetric data. Its rationale is to restore anatomy, secure hemostasis without ischemia, and preserve long-term uterine function. While short-term safety appears comparable across closure methods, evidence increasingly indicates that long-term reproductive outcomes depend on how closure respects tissue biology. We argue that appropriate repair is more important than a fast repair: meticulous restoration of uterine anatomy should take precedence over operative speed. The enduring success of a hysterotomy repair depends on the surgical technique employed, as it directly affects women's future reproductive health.

Natural Conception After Tubal Reconstruction: A Rare Success Following Bilateral Fimbrioplasty for Post-pelvic Inflammatory Disease Occlusion

Kumari S et al., 2025 · Cureus · Open Access

Pelvic inflammatory disease (PID) remains a major cause of tubal factor infertility. Although in vitro fertilization (IVF) has largely replaced reconstructive surgery, selected patients with mild tubal damage may still achieve natural conception after surgical repair. This case highlights a spontaneous conception following bilateral fimbrioplasty in a patient with mild post-PID distal tubal occlusion. A 33-year-old, gravida 4 para 2, woman presented with three years of secondary infertility. Hysterosalpingogram (HSG) showed mild bilateral hydrosalpinx and distal tubal occlusion, with normal ovarian reserve and hormonal evaluation. The patient underwent robotic fimbrioplasty on July 23, 2025. Operative findings included Fitz-Hugh-Curtis changes, bilateral filmy adhesions, and grade-I distal occlusion. Bilateral adhesiolysis and fimbrioplasty were performed with restoration of tubal patency on chromotubation. The postoperative course was uncomplicated. Ten weeks after surgery, the patient conceived spontaneously with a normal intrauterine pregnancy. Tubal reconstructive surgery remains a valuable fertility-preserving option for selected patients who decline or lack access to IVF. Success depends on careful patient selection, minimal tubal damage, and meticulous microsurgical technique. Tubal reconstruction can offer selected women an affordable, fertility-preserving option, especially in low-resource settings where IVF is inaccessible.

Surgery in Restorative Reproductive Medicine

Yeung P, 2025 · J Restorative Reprod Med · Open Access

Restorative reproductive surgery has emerged to become an exciting and promising field of surgery that can transform the way that we treat patients, especially regarding fertility. As a prime example of this type of surgery, restorative reproductive surgery for endometriosis, a common and debilitating disease that can lead to infertility and pelvic pain, offers a root cause treatment to remove the actual disease and to optimize the reproductive anatomy, for best patient outcomes. Optimal excision of endometriosis and prevention of pelvic adhesions has been shown to lead to reduce symptoms, to lead to high natural fertility rates, and to lead to very low rates of the need for repeat surgery. Patients have improved symptoms and quality of life, in addition to improved fertility chances for one and subsequent pregnancies (if desired), demonstrating the link between wellness and fertility. There is an urgent need for more resources, training, advocacy, research and publication for this exciting area of restorative reproductive surgery. Its time has come.

Fertility after expanded polytetrafluoroethylene use after endometrioma cystectomy: a pilot study

Yeung PP Jr et al., 2023 · Front Reprod Health · Open Access

Pregnancy rates after the placement of expanded polytetrafluoroethylene (ePTFE, trade name Gore-Tex®) for adhesion prevention following cystectomy of endometriomas ≥3 cm and excision of endometriosis were analyzed in this pilot study. A prospective cohort study was performed at a single tertiary care center. 56 women qualified for the study and underwent surgery. Expanded polytetrafluoroethylene placement around affected ovaries was self-selected. Inclusion criteria for analysis were pathology-confirmed endometrioma ≥3 cm, no hysterectomy at time of surgery, ≥1 year of postoperative survey completion, and absence of strategies to avoid pregnancy. 18 women in the ePTFE group and 11 women in the control group met inclusion criteria for analysis. 16 of the 18 women in the ePTFE group and 7 of the 11 women in the control group were affected by infertility. Absolute pregnancy rates and cumulative 4-year pregnancy rates, which are based on survival analysis using lifetables and adjust for varying follow-up times, were calculated for all women as well as for women with infertility only. High cumulative 4-year pregnancy rates were observed for women with expanded polytetrafluoroethylene compared to women without (85% vs. 65%, p = 0.69). High cumulative 4-year pregnancy rates for women with infertility prior to surgery were observed for women with expanded polytetrafluoroethylene compared to women without (83% vs. 33%, p = 0.89). There are consistent trends, although not statistically significant, seen in pregnancy rates for women with ePTFE compared to women without, particularly in those with a history of infertility prior to ePTFE use. This is the first study examining how adhesion prevention strategy targeting the adnexa during surgery for endometriosis affects pregnancy rates. The trend towards increased pregnancy rates with expanded polytetrafluoroethylene use, particularly in patients with a history of infertility, is promising and warrants further study with larger groups.

Repair of Isthmocele Following Embolization of Uterine Arteriovenous Malformation

Huang D et al., 2023 · J Minim Invasive Gynecol ·

To present a case of concurrent uterine arteriovenous malformation (AVM) and isthmocele, treated with ethylene vinyl alcohol copolymer (EVAC) embolization of the AVM followed by robotic isthmocele repair. A stepwise video demonstration with narration. A tertiary care academic hospital. Patient is a 37-year-old with one previous cesarean section who presented with persistent heavy vaginal bleeding after a dilation and evacuation procedure. Imaging showed evidence of an isthmocele and an iatrogenic uterine AVM secondary to the dilation and evacuation procedure. Both entities are morbid conditions associated with significant operative blood loss. Embolization of the acquired AVM was first performed to stabilize bleeding. In addition, owing to the extensive uterine defect and history of infertility, surgical repair of the isthmocele was recommended. A multidisciplinary approach combining interventional radiology and gynecologic surgery expertise, implementing several strategies to minimize blood loss: 1. Image-guided uterine AVM embolization with EVAC [1] 2. Hysteroscopic identification of isthmocele and residual EVAC in the cavity, with fluorescence transillumination to clearly delineate isthmocele borders 3. Robot-assisted laparoscopic approach for bladder flap creation, as well as retroperitoneal space dissection to skeletonize uterine arteries 4. Transient occlusion of uterine arteries using vascular clamps to minimize operative blood loss given the isthmocele size and its proximity to the left uterine artery 5. Resection of the isthmocele and removal of residual intracavitary EVAC 6. Multilayer, bidirectional hysterotomy closure and vascular clamp removal to restore uterine blood supply Successful multidisciplinary treatment of concurrent uterine AVM and isthmocele. Cesarean delivery at 36 to 37 weeks' gestational age was recommended for future deliveries.

Efforts to transfer ectopic embryos to the uterine cavity: A systematic review

Thomas C et al., 2023 · J Obstet Gynaecol Res ·

The objectives of this review are to identify and characterize attempts to transfer ectopic embryos to the uterus, and to understand arguments for and against the feasibility of such an intervention. An electronic literature search involved all English language articles published in MEDLINE (1948-), Web of Science (1899-), and Scopus (1960-) before July 1, 2022. Articles were included that identify or describe attempts to transfer the embryo from its ectopic location to the uterine cavity, or discuss the feasibility of such an intervention; there were no exclusion criteria (PROSPERO registration number CRD42022364913). The initial search yielded 3060 articles; 8 articles were included. Of these, two articles were case reports that described the successful transfer of the embryo from its ectopic location to the uterus, followed by term births; both cases involved laparotomy with salpingostomy, followed by transfer of the embryonic sac into the uterine cavity through an opening made in the uterine wall. The other six articles varied in type, and provided a number of arguments for and against the feasibility of such a procedure. The evidence and arguments identified in this review may help manage expectations for those interested in transferring an ectopically implanted embryo in the hope of continuing the pregnancy, but who are uncertain about the extent to which such a procedure has been attempted or may be possible. Isolated case reports, with no evidence of replication, should be interpreted with the utmost caution and do not constitute a procedure for clinical use.

Clinical efficacy of a novel method of fertility-preserving adenomyomectomy in infertile women with diffuse adenomyosis

Yoon SH et al., 2023 · Medicine (Baltimore)

Beneficial and detrimental effect of surgical adenomyomectomy is still controversial in infertile women with severely diffuse adenomyosis. The primary objective of this study was to assess whether a novel method of fertility-preserving adenomyomectomy could improve pregnancy rates. The secondary objective was to evaluate whether it could improve dysmenorrhea and menorrhagia symptoms in infertile patients with severe adenomyosis. A prospective clinical trial was conducted between December 2007 and September 2016. Fifty women with infertility due to adenomyosis were enrolled in this study after clinical assessments by infertility experts. A novel method of fertility-preserving adenomyomectomy was performed on 45 of 50 patients. The procedure included T- or transverse H-incision of the uterine serosa followed by preparation of the serosal flap, excision of the adenomyotic tissue using argon laser under ultrasonographic monitoring, and a novel technique of suturing between the residual myometrium and serosal flap. All patients obtained dysmenorrhea relief 6 months postoperatively (NRS 7.28 vs 1.56, P<.001). The amount of menstrual blood decreased significantly (140.44 vs 66.33 mL, P<.05). Of the 33 patients who attempted pregnancy postoperatively, 18 (54.5%) conceived either by natural means, in vitro fertilization and embryo transfer (IVF-ET), or thawing embryo transfer. Miscarriage occurred in 8 patients, while 10 (30.3%) had viable pregnancies. This novel method of adenomyomectomy resulted in improved pregnancy rates, as well as relief of dysmenorrhea and menorrhagia. This operation is effective in preserving fertility potential in infertile women with diffuse adenomyosis.

Reproductive surgery: revisiting its origins and role in the modern management of fertility

Bortoletto P et al., 2023 · Fertil Steril · Open Access

For years, reproductive surgery was the mainstay of reproductive care. With the evolution and ultimate success of in vitro fertilization (IVF), reproductive surgery became an adjuvant therapy, indicated mainly for severe symptoms or to enhance success rates with assisted reproductive technologies. As success rates for IVF have plateaued, and emerging data rekindles the enormous benefits of surgically correcting reproductive pathologies, there is renewed interest among reproductive surgeons in reviving research and surgical expertise in this area. In addition, new instrumentation and surgical techniques to preserve fertility have gained traction and will solidify the need to have skilled reproductive endocrinology and infertility surgeons in our practice.

The effect of opportunistic salpingectomy for primary prevention of ovarian cancer on ovarian reserve: a systematic review and meta-analysis

Gelderblom ME et al., 2022 · Maturitas

Opportunistic salpingectomy (OS) is an attractive method for primary prevention of ovarian cancer. Although OS has not been associated with a higher complication rate, it may be associated with earlier onset of menopause. To provide a systematic review and meta-analysis of the effect of OS on both age at menopause and ovarian reserve. A search was conducted in the Cochrane Library, Embase and MEDLINE databases from inception until March 2022. We included randomized clinical trials and cohort studies investigating the effect of OS on onset of menopause and/or ovarian reserve through change in anti-Müllerian hormone (AMH), antral follicle count (AFC), estradiol (E2), follicle stimulating hormone (FSH) and luteinizing hormone (LH). Data was extracted independently by two researchers. Random-effects meta-analyses were conducted to estimate the pooled effect of OS on ovarian reserve. The initial search yielded 1047 studies. No studies were found investigating the effect of OS on age of menopause. Fifteen studies were included in the meta-analysis on ovarian reserve. Meta-analyses did not result in statistically significant differences in mean change in AMH (MD -0.07 ng/ml, 95%CI -0.18;0.05), AFC (MD 0.20 n, 95 % CI -4.91;5.30), E2 (MD 3.97 pg/ml, 95%CI -0.92;8.86), FSH (MD 0.33mIU/ml, 95%CI -0.15;0.81) and LH (MD 0.03mIU/ml; 95%CI -0.47;0.53). Our study shows that OS does not result in a significant reduction of ovarian reserve in the short term. Further research is essential to confirm the absence of major effects of OS on menopausal onset since clear evidence on this subject is lacking. Registration number PROSPERO CRD42021260966.

Fluoroscopically-Guided Hysteroscopic Tubal Cannulation: A Procedure for Proximal Tubal Obstruction

Keltz M et al., 2022 · JSLS : Journal of the Society of Laparoendoscopic Surgeons

To evaluate the cannulation success rate, cumulative pregnancy, and time to intrauterine pregnancy rate following fluoroscopically-guided hysteroscopic tubal cannulation (FHTC) for infertile subjects with proximal tubal obstruction. This retrospective study evaluated subjects with unilateral or bilateral proximal tubal obstruction on hysterosalpingography, who failed concomitant selective salpingography and subsequently underwent FHTC at the time of a hysteroscopy performed for findings seen on sonohysterography. FHTC employed a Novy Catheter (CooperSurgical, Inc, Trumbull, CT.) with or without the 3 French inner catheter and guidewire, to cannulate the occluded fallopian tube(s), followed by the injection of HypaqueTM (Amersham Health, Inc, Princeton, NJ.) contrast under C-arm imaging. Technical success rates, complications, post-procedure pregnancies, and average time from surgery to pregnancy were evaluated. Thirty-two women between January 1, 2017 and December 31, 2019 met the entry criteria and underwent FHTC. Of those women with bilateral obstruction, 6/6 (100%) of subjects achieved at least unilateral patency, while patency was achieved in 23/26 (88.5%) subjects with unilateral obstruction. Twenty-nine of 32 (90.6%) subjects had at least one tube successfully cannulated with 34/38 (89.5%) of proximally obstructed tubes opened. Asymptomatic tubal perforation occurred in 1/38 tubes (2.6%). Ten subjects (34.5%) achieved intrauterine pregnancies without in vitro fertilization in an average of 64.9 days from the procedure. There were no multiple pregnancies and one ectopic pregnancy. FHTC is a safe, effective, incision free procedure that results in 90% of tubes successfully cannulated, and an observed short time to intrauterine pregnancy.

Robot-assisted laparoscopy repair of uterine isthmocele: A two-center observational study

Cardaillac C et al., 2022 · Int J Gynaecol Obstet ·

To analyze outcomes and postoperative complications in patients undergoing robot-assisted isthmocele repair. This retrospective cohort study included 33 patients who had robot-assisted laparoscopic surgical management of an isthmocele between September 2013 and August 2020 in two French university hospitals. All charts were reviewed to identify patient characteristics, preoperative and postoperative anatomical findings, complications, and postoperative fertility and symptoms. Patients who had undergone this procedure were asked to complete a telephone questionnaire about their treatment satisfaction and symptoms. The isthmocele was discovered most often as a result of subfertility (57.6%), but also ectopic pregnancy (18.2%), pelvic pain (15.2%), and postmenstrual bleeding (9.1%). Robot-assisted repair of the isthmocele significantly improved myometrial thickness (from 1.55 mm before surgery to 4.26 mm after surgery [mean difference 2.71; 95% confidence interval, 1.91-3.51], P = 0.0005). Among 20 patients who still desired a child after surgery, 15 became pregnant and 14 had full-term live births. Among the nine patients who had surgery for disabling symptoms, five had no persistent symptoms, three reported global improvement, and one had the same gynecologic discomfort. Seventeen patients agreed to complete the questionnaires (51.5%), and all stated that they would choose to have this surgery again. Robot-assisted repair of an isthmocele is a viable minimally invasive procedure.

Is There Still a Place for Reconstructive Surgery in Distal Tubal Disease?

Obrzut B et al., 2022 · Journal of clinical medicine · Open Access

Tubal diseases account for 25-40% of female factor infertility. Mainly, they involve the distal part of the fallopian tube, and hydrosalpinx is the most severe manifestation. Usually, the management decision is made between reconstructive surgery and ART, depending on the severity of the tubal damage, patient age, ovarian reserve, and seminogram, as well as financial, religious, ethical, and psychological factors. Estimated live-birth rates after corrective surgery range from 9% to 69%. The success rate of IVF is about 30% live-birth rate per cycle initiated in women across all ages with tubal factor infertility. Surgery offers a long-term cure and patients may attempt conception many times but are burdened with perioperative adverse events. IVF bypasses potential complications of operative treatment; however, this has its own unique risks. The effectiveness of reconstructive surgery versus ART has not been adequately evaluated. The success of fertility management depends on a thorough interpretation of existing data and careful patient selection. The presented review provides updates on the most recent progress in this area.

Laparoscopic ovarian drilling for ovulation induction in women with anovulatory polycystic ovary syndrome

Bordewijk EM et al., 2020 · The Cochrane database of systematic reviews

Polycystic ovary syndrome (PCOS) is a common condition affecting 8% to 13% of reproductive-aged women. In the past clomiphene citrate (CC) used to be the first-line treatment in women with PCOS. Ovulation induction with letrozole should be the first-line treatment according to new guidelines, but the use of letrozole is off-label. Consequently, CC is still commonly used. Approximately 20% of women on CC do not ovulate. Women who are CC-resistant can be treated with gonadotrophins or other medical ovulation-induction agents. These medications are not always successful, can be time-consuming and can cause adverse events like multiple pregnancies and cycle cancellation due to an excessive response. Laparoscopic ovarian drilling (LOD) is a surgical alternative to medical treatment. There are risks associated with surgery, such as complications from anaesthesia, infection, and adhesions. To evaluate the effectiveness and safety of LOD with or without medical ovulation induction compared with medical ovulation induction alone for women with anovulatory polycystic PCOS and CC-resistance. We searched the Cochrane Gynaecology and Fertility Group (CGFG) trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers up to 8 October 2019, together with reference checking and contact with study authors and experts in the field to identify additional studies. We included randomised controlled trials (RCTs) of women with anovulatory PCOS and CC resistance who underwent LOD with or without medical ovulation induction versus medical ovulation induction alone, LOD with assisted reproductive technologies (ART) versus ART, LOD with second-look laparoscopy versus expectant management, or different techniques of LOD. Two review authors independently selected studies, assessed risks of bias, extracted data and evaluated the quality of the evidence using the GRADE method. The primary effectiveness outcome was live birth and the primary safety outcome was multiple pregnancy. Pregnancy, miscarriage, ovarian hyperstimulation syndrome (OHSS), ovulation, costs, and quality of life were secondary outcomes. This updated review includes 38 trials (3326 women). The evidence was very low- to moderate-quality; the main limitations were due to poor reporting of study methods, with downgrading for risks of bias (randomisation and allocation concealment) and lack of blinding. Laparoscopic ovarian drilling with or without medical ovulation induction versus medical ovulation induction alone Pooled results suggest LOD may decrease live birth slightly when compared with medical ovulation induction alone (odds ratio (OR) 0.71, 95% confidence interval (CI) 0.54 to 0.92; 9 studies, 1015 women; I2 = 0%; low-quality evidence). The evidence suggest that if the chance of live birth following medical ovulation induction alone is 42%, the chance following LOD would be between 28% and 40%. The sensitivity analysis restricted to only RCTs with low risk of selection bias suggested there is uncertainty whether there is a difference between the treatments (OR 0.90, 95% CI 0.59 to 1.36; 4 studies, 415 women; I2 = 0%, low-quality evidence). LOD probably reduces multiple pregnancy rates (Peto OR 0.34, 95% CI 0.18 to 0.66; 14 studies, 1161 women; I2 = 2%; moderate-quality evidence). This suggests that if we assume the risk of multiple pregnancy following medical ovulation induction is 5.0%, the risk following LOD would be between 0.9% and 3.4%. Restricting to RCTs that followed women for six months after LOD and six cycles of ovulation induction only, the results for live birth were consistent with the main analysis. There may be little or no difference between the treatments for the likelihood of a clinical pregnancy (OR 0.86, 95% CI 0.72 to 1.03; 21 studies, 2016 women; I2 = 19%; low-quality evidence). There is uncertainty about the effect of LOD compared with ovulation induction alone on miscarriage (OR 1.11, 95% CI 0.78 to 1.59; 19 studies, 1909 women; I2 = 0%; low-quality evidence). OHSS was a very rare event. LOD may reduce OHSS (Peto OR 0.25, 95% CI 0.07 to 0.91; 8 studies, 722 women; I2 = 0%; low-quality evidence). Unilateral LOD versus bilateral LOD Due to the small sample size, the quality of evidence is insufficient to justify a conclusion on live birth (OR 0.83, 95% CI 0.24 to 2.78; 1 study, 44 women; very low-quality evidence). There were no data available on multiple pregnancy. The likelihood of a clinical pregnancy is uncertain between the treatments, due to the quality of the evidence and the large heterogeneity between the studies (OR 0.57, 95% CI 0.39 to 0.84; 7 studies, 470 women; I2 = 60%, very low-quality evidence). Due to the small sample size, the quality of evidence is not sufficient to justify a conclusion on miscarriage (OR 1.02, 95% CI 0.31 to 3.33; 2 studies, 131 women; I2 = 0%; very low-quality evidence). Other comparisons Due to lack of evidence and very low-quality data there is uncertainty whether there is a difference for any of the following comparisons: LOD with IVF versus IVF, LOD with second-look laparoscopy versus expectant management, monopolar versus bipolar LOD, and adjusted thermal dose versus fixed thermal dose. AUTHORS' Laparoscopic ovarian drilling with and without medical ovulation induction may decrease the live birth rate in women with anovulatory PCOS and CC resistance compared with medical ovulation induction alone. But the sensitivity analysis restricted to only RCTs at low risk of selection bias suggests there is uncertainty whether there is a difference between the treatments, due to uncertainty around the estimate. Moderate-quality evidence shows that LOD probably reduces the number of multiple pregnancy. Low-quality evidence suggests that there may be little or no difference between the treatments for the likelihood of a clinical pregnancy, and there is uncertainty about the effect of LOD compared with ovulation induction alone on miscarriage. LOD may result in less OHSS. The quality of evidence is insufficient to justify a conclusion on live birth, clinical pregnancy or miscarriage rate for the analysis of unilateral LOD versus bilateral LOD. There were no data available on multiple pregnancy.

Fertility and pregnancy outcomes following hysteroscopic metroplasty of different sized uterine septa: A retrospective cohort study protocol

Wang X et al., 2019 · Medicine (Baltimore) · Open Access

Different sizes of uterine septum between infertile women and patients with abortions may have a clinical relevance in reproductive performance after surgery. This study aimed to assess if the fecundity of women after surgical correction of the uterine septum is associated with septum size.A retrospective, single-center, cohort study was conducted in Peking Union Medical College Hospital using patients aged between 21 and 37 years. Hysteroscopic metroplasty was performed on 121 patients with a uterine septum. The septum size was assessed by ultrasonography and hysteroscopy. The subjects were divided into 3 groups: Group A consisted of 35 women with complete uterine septum (mean ± standard deviation (SD) age 28.29 ± 3.53; group B consisted of 48 women with uterine septum >2.5 cm (mean ± SD age 28.85 ± 3.63); and group C consisted of 48 women with uterine septum ≤2.5 cm (mean ± SD age 28.79 ± 3.74). Age and body mass index (BMI) were not significantly different among the 3 groups.No serious hysteroscopic complications occurred. However, uterine septa were observed in 4 cases after surgery and 6 cases of intrauterine adhesions were observed after long-term follow-up. The abortion rate decreased, and term delivery rate increased significantly in the 3 groups after hysteroscopic metroplasty. The infertility rate was significantly lower in group C after surgery. However, no significant difference was observed in the infertility rate between groups A and B. The recurrent abortion rate was significantly lower in group A than in groups B and C before surgery. After surgery, the infertility rate was significantly higher in group A than in group B (28.57% and 10.53%, respectively; P = .048). After at least 12-months of follow-up, the pregnancy rate in group A was significantly lower than that in group C (71.43% and 89.47%, respectively; P = .048).Uterine septum resection improves obstetrical outcomes. After surgery, the infertility rate was significantly higher in patients with complete uterine septum than in those with a large partial uterine septum, and the pregnancy rate in patients with complete uterine septum was lower than that in the patients with a small partial uterine septum.

Laparoscopic Fimbrioplasty and Neosalpingostomy in Female Infertility: A Review of 402 Cases at the Gynecological Endoscopic Surgery and Human Reproductive Teaching Hospital in Yaoundé-Cameroon

Kasia JM et al., 2016 · J Reprod Infertil ·

More than 70 million couples suffer from infertility worldwide. The aim of this study was to evaluate the fertility outcomes after laparoscopic fimbrioplasty and neosalpingostomy in female infertility. Laparoscopic distal tuboplasty was carried out for 402 cases at the Gynecological Endoscopic Surgery and Human Reproductive Teaching Hospital in Yaoundé-Cameroon in Central Africa from December 2002 to December 2007. Laparoscopic fimbrioplasty and neosalpingostomy were done using bipolar electrocoagulation and conventional endoscopic instruments. Log-rank test was used to compare cumulative rate curves of intrauterine pregnancy with respect to the tubal stages. P<0.05 was considered statistically significant. The mean age of the patients was 31.6±5.45 years. Secondary infertility was the most frequent type of infertility (70.14%). The laparoscopic tubal surgery done consisted of fimbrioplasty in 185(46%) cases and neosalpingostomy in 217 (54%) cases. Of 260 women followed up after tuboplasty, there were overall 74 (28.48%) pregnancies; 68(26.1%) intrauterine pregnancies and 6(2.3%) ectopic pregnancies. Pregnancy rates were significantly associated to the tubal stage (63% in stage 1, 15% in stage 3 and 00% in stage 4; p<0.001) and the adnexal adhesion scores (73.91% in the absence of adnexal adhesions and 8.8% in the case of a severe adnexal adhesion score). Of the 68 intrauterine pregnancies, there were 60(88%) live births and 8(12%) spontaneous abortions. It is believed that laparoscopic fimbrioplasty and neosalpingostomy should be the preferred choice when faced with tubal distal occlusion in a context of female infertility. This implies that training in endoscopic surgery should be regarded as an important issue in developing countries.

Effectiveness of bilateral tubotubal anastomosis in a large outpatient population

Berger GS et al., 2016 · Hum Reprod · Open Access

Is bilateral tubotubal anastomosis a successful treatment in an outpatient patient population? For women wanting children after tubal sterilization, bilateral tubotubal anastomosis is an effective outpatient treatment. With the current emphasis in reproductive medicine on high technology procedures, the effectiveness of female surgical sterilization reversal is often overlooked. Previous clinical studies of tubal sterilization reversal have been mostly retrospective analyses of small patient populations. STUDY DESIGN, SIZE, A cohort of women who underwent outpatient bilateral tubotubal anastomosis from January 2000 to June 2013 was followed prospectively until December 2014 to determine the proportions of women undergoing the procedure who became pregnant and who had live births. Data were collected at the time of pregnancy. Differences in pregnancy rates and live birth rates associated with age, race and sterilization method were evaluated. PARTICIPANTS/MATERIALS, SETTING, A total of 6692 women, aged 20-51 years, underwent outpatient bilateral tubotubal anastomosis. MAIN The crude overall pregnancy rate was 69%. The crude overall birth rate was 35%. Results varied according to age at sterilization reversal and the method of sterilization. Women under 30 years of age at reversal of ring/clip sterilizations had an 88% pregnancy rate and 62% birth rate. Pregnancy and birth rates declined as age increased at sterilization reversal. Coagulation sterilization reversals resulted in the lowest rates of pregnancies and births. Ligation/resection reversals had intermediate success rates. LIMITATIONS, Limitations of our study include probable underreporting of pregnancies based on patient-initiated reports; possible errors in the reporting of pregnancies or early miscarriages that may have been based solely on home pregnancy tests; and probable over-reporting of the diagnosis of ectopic pregnancies. We identified age and sterilization method as being associated with subsequent pregnancy, however, in order to be considered predictive, the associations would need to be validated in an independent second prospectively studied group of representative patients. Finally, we also included patients in the study population who had additional surgical procedures performed at the time of tubotubal anastomosis (e.g. uterine myomectomy, fimbrioplasty, ovarian cystectomy and adhesiolysis), factors that could result in differences in pregnancy statistics in our study versus other patient populations. The results of this study can help inform patients and clinicians about this low technology alternative to IVF. None. N/A.

Clinical Effectiveness of Modified Laparoscopic Fimbrioplasty for the Treatment of Minimal Endometriosis and Unexplained Infertility

Franjoine SE et al., 2015 · Minimally invasive surgery · Open Access

Objective. To study the reproductive outcomes of modified laparoscopic fimbrioplasty (MLF), a surgical technique designed to increase the working surface area of the fimbriated end of the fallopian tube. We postulated that an improvement in fimbrial function through MLF will improve reproductive outcomes. Design. Retrospective cohort study. Setting. Academic tertiary-care medical center. Patients. Women with minimal endometriosis or unexplained infertility, who underwent MLF during diagnostic laparoscopy (n = 50) or diagnostic laparoscopy alone (n = 87). Intervention. MLF involved gentle, circumferential dilatation of the fimbria and lysis of fimbrial adhesions bridging the fimbrial folds. Main Outcome Measures. The primary outcome was pregnancy rate and the secondary outcome was time to pregnancy. Results. The pregnancy rate for the MLF group was 40.0%, compared to 28.7% for the control group. The average time to pregnancy for the MLF group was 13 weeks, compared to 18 weeks for the control group. The pregnancy rate in the MLF group was significantly higher for patients ≤35 ys (51.5% versus 28.8%), but not for those >35 ys (17.6% versus 28.6%). Conclusion. MLF was associated with a significant increase in pregnancy rate for patients ≤35 ys.

Relationship between ovarian cysts and infertility: what surgery and when?

Legendre G et al., 2014 · Fertility and sterility

The relationship between ovarian cysts and infertility is a subject of debate, mainly because it is difficult to determine the real impact of the cyst and its treatment on later fertility. For a long time it was hoped that surgical treatment could prevent potential complications (such as rupture or malignancy). For presumed benign ovarian tumors, fertility sparing should be the main concern. The goal of this survey of current knowledge on the subject is to thoroughly explore the potential relationship between cysts, their treatment, and infertility. Our study is based on a review of the literature dealing with the epidemiology of ovarian cysts and the effects of their surgical management in relation to infertility. Analysis of the epidemiologic data, drawn mainly from comparative studies and cohorts, shows that the role of cysts in infertility is controversial and that the effects of surgical treatment are often more harmful than the cyst itself to the ovarian reserve. Surgery does not seem to improve pregnancy rates. When a surgical option is nonetheless chosen, a conservative laparoscopic approach is more suitable. Besides excision, sclerotherapy and plasma vaporization are promising, offering a greater preservation of the ovarian parenchyma, especially in endometriomas. These techniques must be better defined. The context of the infertility is essential, and surgeons and specialists in reproductive medicine should decide management jointly.

Anti-N-methyl-aspartate receptor encephalitis in identical twin sisters: role for oophorectomy

Masghati S et al., 2014 · Obstetrics & Gynecology

Anti-N-methyl-aspartate receptor encephalitis is a potentially fatal form of encephalitis and frequently associated with ovarian teratomas. Surgical removal of ovarian teratomas improves clinical outcome, but it is unclear whether bilateral salpingo-oophorectomy for normal-appearing ovaries is of clinical benefit. Our report describes a unique clinical scenario of identical twin sisters with anti-N-methyl-aspartate receptor encephalitis. Neither patient responded to immunosuppressive therapy. Imaging studies showed normal-appearing ovaries. The first twin continued on medical therapy only and died of the disease. The second twin underwent a bilateral salpingo-oophorectomy followed by gradual recovery. Based on our experience in two genetically identical individuals, we suggest considering the removal of normal-appearing ovaries in patients with anti-N-methyl-aspartate receptor encephalitis who fail to respond to medical treatment.

Incarcerated Omentum With Tamponade Effect in the Uterine Perforation Scar After Dilation and Curettage: A Case Report

Kim KW, 2014 · J Med Cases · Open Access

Perforation of the uterus is the most common immediate complication at the time of dilatation and curettage (D&C). We experienced the case of a patient with intra-abdominal extrusion of fetal part and incarcerated omentum in the perforation site of uterine fundus after D&C. It resulted in massive bleeding after the reduction of the incarcerated omentum which had a tamponade effect. A 26-year-old gravida 2, para 1 woman was referred to our hospital because of uterine perforation during D&C. A laparoscopic exploration was performed. Bleeding started massively at the perforation scar after reduction of the incarcerated omentum which had a tamponade effect. Though bleeding from perforation site stopped after laparoscopic myometrial repair, vaginal bleeding persisted further. The placing of an intrauterine balloon tamponade stopped the vaginal bleeding. The patient recovered successfully and was discharged on the fifth postoperative day. J Med Cases. 2014;5(4):204-207 doi: http://dx.doi.org/10.14740/jmc1713w

Does unilateral laparoscopic diathermy adjusted to ovarian volume increase the chances of ovulation in women with polycystic ovary syndrome?

Sunj M et al., 2013 · Hum Reprod ·

Does unilateral volume-adjusted laparoscopic diathermy increase the chances of ovulation in women with polycystic ovary syndrome (PCOS)? Although unilateral laparoscopic ovarian drilling (ULOD) using adjusted thermal doses was more efficient than bilateral laparoscopic ovarian drilling (BLOD) using fixed doses, the chances of ovulation were improved in patients irrespective of the technique used. The adjustment of the thermal dose to ovarian volume in BLOD increases ovulation and pregnancy rates compared with fixed-dose treatment, but BLOD causes the formation of adhesions, particularly on the left ovary, and increases the risk of damage to ovarian tissue. In contrast, ULOD with a fixed thermal dose minimizes the risk of ovarian tissue damage, and can increase the activity in both right and left ovaries, although this varies in humans and in other species. STUDY DESIGN, SIZE, This prospective, longitudinal, study, between September 2009 and January 2013, included 96 infertile women with PCOS who were unresponsive to clomiphene citrate treatment and had underwent either ULOD or BLOD. After surgery, the groups were followed up for 6 months to assess ovulatory response. PARTICIPANTS/MATERIALS, SETTING, Patients were assigned to two groups; one group underwent laparoscopic ovarian drilling of the right ovary alone, while both ovaries were treated in the second group. The ULOD group (n = 49) received thermal doses adjusted to the volume of the right ovary (60 J/cm³). The BLOD group (n = 47) received fixed doses of 600 J per ovary, regardless of its volume. The two treatment groups were matched by the number of participants, age and baseline parameters. MAIN The ovulation rate during the first menstrual cycle after LOD was significantly higher in the ULOD group than in the BLOD group [73 versus 49%; absolute risk reduction (ARR), -0.25; 95% confidence interval (CI), -0.44 to -0.03; P = 0.014]. Treatment with ULOD on the right ovary significantly increased the chances of ovulation in patients with a larger right ovary compared with those who had a smaller right ovary (100 versus 36%; ARR, -0.64; 95% CI, -0.84 to -0.37; P = 0.004). Interestingly, the chances of ovulation were also significantly higher in patients in the BLOD group who had a larger right ovary compared with those who had a smaller right ovary (88 versus 33%; ARR, -0.55; 95% CI, -0.73 to -0.28; P = 0.002). The pregnancy rate was also significantly higher in patients with a larger right ovary compared with those with a smaller right ovary, regardless of the treatment group. LIMITATIONS, The 6-month follow-up was too short to demonstrate any long-term differences in the ovulation rates. Future research should therefore extend the follow-up beyond 6 months. Another limitation is that ULOD was used to treat only the right ovary. Future studies should investigate whether ULOD treatment of the larger ovary, whether left or right, would significantly increase the ovulation rate. This study represents an advance in the determination of the optimal laparoscopic treatment for women with PCOS, as it was shown that improved results can be achieved using less thermal energy in volume-adjusted ULOD.

Adhesion prevention in endometriosis: a neglected critical challenge

Somigliana E et al., 2012 · J Minim Invasive Gynecol ·

Prevention of adhesions, whether de novo or by re-formation, is one of the most important and surprisingly neglected aspect of the treatment of endometriosis. Adhesions may cause infertility, dyspareunia, chronic pelvic pain but also intestinal obstruction and complications at subsequent surgery. They may play a role in the development of some forms of the disease such as ovarian endometriomas and possibly also deep invasive nodules. Three randomized controlled trials have been published documenting some partial success with Interceed, Oxiplex/AP gel or Adept solution in reducing adhesions extent at second look laparoscopy performed a few weeks after initial surgery. However, data on relevant long-term outcomes such as fertility, pelvic pain or disease recurrences or other adhesions-related complications is lacking. Noteworthy, endometriosis is a chronic inflammatory disorder and the insult causing adhesions is expected to persist after surgery. Therefore preventing adhesion formation with exclusively agents at the time of surgery may be insufficient. Future studies should focus on a 2-step strategy that includes measures applied at the time of surgery and subsequent administration of agents able to prevent the development of new adhesions.

Renaissance of surgical recanalization for proximal fallopian tubal occlusion: falloposcopic tuboplasty as a promising therapeutic option in tubal infertility

Tanaka Y et al., 2011 · J Minim Invasive Gynecol ·

To assess the clinical effectiveness of falloposcopic tuboplasty in tubal infertility. Retrospective cohort study (Canadian Task Force classification II-3). Infertility clinic. Three hundred forty-five infertile patients (≥2y) with a diagnosis of proximal tubal occlusion, either bilateral or unilateral, between January 2005 and January 2011. Falloposcopic tuboplasty. MAIN Medical records for 345 patients with a diagnosis of proximal tubal occlusion were reviewed. Of the 345 patients, 304 underwent falloposcopic tuboplasty, with successful recanalization achieved in 248 patients (81.6%). Ninety-one of the 304 patients (29.9%) became pregnant. Of these, 18 patients (19.8%) miscarried, and 4 (4.4%) had ectopic pregnancies in the recanalized tube. At 1-, 3-, 6-, and 9-month follow-up, the cumulative probability of conception was 23.1%, 50.6%, 73.6%, and 82.4%, respectively. Related complications included postsurgical infection (0.3%), perforation of the fallopian tube (1.3%), and accidental breakage of the catheter (4.9%) or the falloposcope (1.3%). Falloposcopic tuboplasty is safe and effective for treatment of tubal infertility. The pregnancy rate after falloposcopic tuboplasty is comparable to that after in vitro fertilization, which suggests that it can be an alternative to in vitro fertilization in women with tubal infertility.

Current practice in tubal surgery and adhesion management: a review

Watrelot A et al., 2011 · Reprod Biomed Online ·

The diminished role of tubal surgery in infertile women following widespread access to IVF is now being reviewed as more patients and surgeons today consider tubal surgery as an effective alternative to assisted reproduction treatment in certain circumstances. The limitations of and lack of patient acceptance of assisted reproduction treatment for ethical and moral reasons have contributed to this change as well as advances in surgical techniques and instrument technology, notably developments in endoscopic surgery. Strategies in tubal surgery are largely unchanged but the mini-invasive nature of the endoscopic approach has added value because of less tissue trauma, better visualization of the operative field and more rapid healing, which make surgery using today's techniques an integral part of the treatment strategy in infertile couples.

Near Adhesion-Free Reconstructive Pelvic Surgery: Three Distinct Phases of Progress Over 23 Years

Hilgers TW, 2010 · Journal of Gynecologic Surgery ·

A somewhat pessimistic view on the prevention of postsurgical adhesions has developed over the years because rigorous surgical approaches may still result in the formation of postsurgical adhesions. In addition, postsurgical adhesion formation is associated with a significant degree of long-term morbidity. In this article, a surgical technique is presented which allows patients with the most extensive form of pelvic adhesions to undergo reconstructive pelvic surgery with a near–adhesion-free postoperative outcome. This study was undertaken to assess the effectiveness of a comprehensive, well-defined set of surgical techniques, with well-defined additions and subtractions in surgical technique over a period of 23 years and three distinct phases of implementation. This work was a systematic comparison of three case-series evaluated sequentially over time. The three surgical protocols were each completely standardized. This was a systematic comparison of three distinct case series of patients who had extensive pelvic adhesions. Three distinct and standardized surgical protocols were prospectively introduced and adhesion scores before and after surgical treatment were assessed and statistically compared for each of the three case series. Ninety-five (95) patients with extensive pelvic adhesive disease due to endometriosis or pelvic inflammatory disease participated in this assessment. They were chosen because of the extensive nature of their pelvic and adnexal adhesions. There were 26 patients in phase I (1987–1993), 44 patients in phase II (1994–2005), and 25 patients in phase III (2006–2009). Using the American Fertility Society scoring system for adnexal adhesions, the total adhesion score decreased from 33.8 to 18.1 in phase I, from 33.3 to 6.0 in phase II, and from 33.2 to 2.5 in phase III. Each decrease was statistically significant within each phase (P < 0.001). Further, a statistically significant decrease in subsequent adhesion scores (P < 0.01) was observed at the time of second-look laparoscopy, when comparing phases I to II, II to III, and I to III, with the lowest scores obtained with the phase III surgical techniques. With the use of a comprehensive, well-defined set of surgical antiadhesion techniques, it is possible to perform adhesion-free or near adhesion-free reconstructive pelvic surgery. (J GYNECOL SURG 26:31)

Postoperative procedures for improving fertility following pelvic reproductive surgery

Duffy JM et al., 2009 · The Cochrane database of systematic reviews · Open Access

Hydrotubation with oil-soluble contrast media for unexplained infertility and adhesiolysis for infertility due to peritubal adhesions are primary procedures that are of recognised benefit. It is less clear whether postoperative procedures such as hydrotubation or second-look laparoscopy with adhesiolysis are beneficial following pelvic reproductive surgery. To assess the value of postoperative hydrotubation and second-look laparoscopy with adhesiolysis following female pelvic reproductive surgery. We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register (August 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to August 2008), EMBASE (1980 to August 2008), PsycINFO (1967 to August 2008), Current Contents (1993 to August 2008), Biological Abstracts (1969 to August 2008), CINAHL (1982 to August 2008) and reference lists of identified articles. All randomised controlled trials in which a postoperative procedure was compared with a control group following pelvic reproductive surgery were considered for inclusion in the review. Five randomised controlled trials were identified and included in this updated review. An attempt was made to obtain further information from the authors of all five trials. All trials were assessed for quality. The studied outcomes were pregnancy, live birth, ectopic pregnancy and miscarriage rates, and the rates of tubal patency and procedure-related complications. Review authors extracted the data independently and the odds ratios (OR) were estimated for these dichotomous outcomes. Five randomised controlled trials were identified and included in this review. The odds of pregnancy (OR 1.12, 95% confidence interval (CI) 0.57 to 2.21) and live birth (OR 0.61, 95% CI 0.24 to 1.59) were not significantly different with postoperative hydrotubation versus no hydrotubation. The odds of pregnancy (OR 0.96, 95% CI 0.44 to 2.07) or live birth (OR 0.67, 95% CI 0.19 to 2.32) were also not significantly different with second-look laparoscopy and adhesiolysis versus no second-look laparoscopy. Whether hydrotubation was early or late and whether hydrotubation fluid contained steroid or not had no significant impact on the odds of pregnancy or live birth. Late antibiotic hydrotubation increased the odds of at least one patent fallopian tube when compared with early hydrotubation in women (OR 7.72, 95% CI 2.50 to 8.93). The odds of infective morbidity significantly increased with early hydrotubation when compared with late non-antibiotic hydrotubation (OR 4.72, 95% CI 2.50 to 8.93). When comparing late hydrotubation following tubal stent removal with early hydrotubation in women who had no tubal stenting, there was no significant difference in pregnancy or live birth rates. AUTHORS' There is insufficient evidence to support the routine practice of hydrotubation or second-look laparoscopy following female pelvic reproductive surgery. The studies on which this conclusion is based were either of poor quality or underpowered. These interventions should be performed in the context of a good quality, adequately powered randomised controlled trial. Postoperative hydrotubation with fluid containing antibiotic may offer benefit over hydrotubation fluid without antibiotic following tubal surgery. A randomised controlled trial of postoperative hydrotubation with antibiotic-containing fluid versus no hydrotubation for improving fertility following tubal surgery is justified.

American Obstetrics and Gynecology 1850-1930 (history of gynecologic surgery)

Cyr RM, 2009 · ACOG Annual Meeting poster

Historical poster presented at the 2009 ACOG Annual Meeting by Ronald M. Cyr, MD, FACOG, tracing the development of American obstetrics and gynecology from 1850 to 1930, including the early history of ovariotomy and gynecologic surgery.

Adhesion-related readmissions following gynaecological laparoscopy or laparotomy in Scotland: an epidemiological study of 24 046 patients

Lower A et al., 2004 · Hum Reprod ·

Gynaecological laparotomies are associated with considerable adhesion-related burdens; however, few data are available concerning laparoscopic surgery. This study evaluated the epidemiology of adhesion-related readmissions following open and laparoscopic procedures. Records from 24,046 patients undergoing gynaecological surgery in Scottish National Health Service hospitals during 1996 were assessed retrospectively. Cohorts comprised 15,197 patients undergoing laparoscopic surgery and 8849 patients undergoing laparotomies. Adhesion-related readmission episodes (directly and possibly related) were assessed over 4 years following initial surgery and were expressed as percentages of the number of initial procedures. Directly adhesion-related readmissions 1 year after initial laparoscopic surgery were: in the high-risk group (adhesiolysis and cyst drainage) 1.3%; medium-risk (therapeutic and diagnostic procedures not categorized as highor low-risk) 1.5%; and low-risk (Fallopian tube sterilizations) 0.2%. Readmissions for laparotomy following surgery on the Fallopian tubes were 0.9%, ovaries 2.1%, uterus 0.6% and vagina 0%. Readmissions occurred at reduced rates in the second, third and fourth years after surgery. Exclusion of patients who underwent surgery within the previous 5 years resulted in reduced readmission rates following laparotomy and high-risk laparoscopy. With the exception of laparoscopic sterilizations, open and laparoscopic gynaecological surgery are associated with comparable risks of adhesion-related readmissions.

Chapter 78: Management of Ectopic Pregnancies

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Ectopic pregnancy demands prompt diagnosis and intervention to prevent life-threatening hemorrhage, and NaProTECHNOLOGY's CrMS-guided cycle monitoring enables earlier detection compared to symptom-driven presentations. Surgical management favors salpingotomy with tube preservation when feasible, aligned with the NaProTECHNOLOGY commitment to maintaining reproductive anatomy and future fertility potential.

Chapter 77: PEARS for the Fallopian Tubes: Proximal Tubal Occlusion with Tubal Reimplantation

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Proximal tubal occlusion at the uterotubal junction, whether from salpingitis isthmica nodosa, fibrosis, or prior sterilization, requires cornual resection and microsurgical tubal reimplantation to re-establish luminal continuity. NaProTECHNOLOGY treats this as a reconstructive procedure rather than a reason to defer to IVF, and outcomes data support intrauterine pregnancy rates comparable to assisted reproduction in appropriately selected patients.

Chapter 82: Postoperative Care and Complications

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Structured postoperative management following PEARS procedures addresses wound care, pain control, early ambulation, hormonal support, and surveillance for complications including bleeding, infection, urinary injury, and bowel complications. NaProTECHNOLOGY postoperative protocols integrate CrMS-guided hormonal monitoring to optimize the healing environment and time the resumption of targeted fertility treatment.

Chapter 76: PEARS for the Fallopian Tubes: Distal Occlusions and Other Applications

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Distal tubal occlusion — including hydrosalpinx, fimbrial agglutination, and peritubal adhesions — is a correctable cause of tubal-factor infertility amenable to salpingoneostomy, fimbrioplasty, and adhesiolysis under PEARS principles. Restoration of distal tubal patency and normal fimbrial architecture allows natural conception and avoids the bypassing of physiological fertilization that characterizes assisted reproductive technology.

Chapter 69: Laparoscopic Laser Lysis of Adhesions

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Laser adhesiolysis protocols address peritubal, periovarian, and cul-de-sac adhesions using CO2 laser energy applied under direct near-contact visualization, with attention to underlying anatomy and vascular proximity. Restoration of normal adnexal mobility and tubo-ovarian relationships is a prerequisite for improved cycle-based fertility after surgical NaProTECHNOLOGY intervention.

Chapter 44: Pelvic Adhesive Disease

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Pelvic adhesions from prior infection, surgery, or endometriosis restrict tubal motility, occlude the fimbriae, and distort ovarian-tubal relationships, constituting a primary mechanical barrier to natural conception. Microsurgical adhesiolysis performed under NaProTECHNOLOGY protocols achieves tubal patency and restores anatomical relationships, enabling natural pregnancy in a substantial proportion of cases that would otherwise be directed to IVF.

Chapter 67: Fundamental Anti-Adhesion Surgical Techniques

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Core microsurgical principles for adhesion prevention—continuous peritoneal irrigation, meticulous hemostasis, minimal thermal spread, avoidance of foreign material, and precise tissue approximation—are detailed as non-negotiable standards in every NaProTECHNOLOGY procedure. Postoperative adhesion formation is the primary cause of surgical failure in pelvic reconstruction, making preventive technique as important as the corrective intervention itself.

Chapter 75: PEARS for Polycystic Ovaries: Ovarian Wedge Resection

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Ovarian wedge resection reduces androgen-producing stromal tissue in women with polycystic ovary syndrome who have failed medical ovulation induction, restoring spontaneous or treatment-responsive ovulatory cycles. Within NaProTECHNOLOGY, the procedure is performed with precise tissue economy and anti-adhesion technique to preserve ovarian reserve while correcting the underlying hormonal dysfunction identified through CrMS biomarker monitoring.

Chapter 74: PEARS for Uterine Leiomyomata: Myomectomy

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Uterine fibroids contribute to abnormal uterine bleeding, dysmenorrhea, recurrent pregnancy loss, and implantation failure, making myomectomy a central NaProTECHNOLOGY surgical intervention for women seeking conception. PEARS myomectomy technique prioritizes uterine preservation, meticulous layered closure of the myometrial defect, and hemostasis strategies that minimize adhesion formation and support subsequent pregnancy.

Chapter 73: PEARS for Extensive Pelvic Adhesive Disease

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Extensive pelvic adhesions — often the sequela of prior surgeries, infection, or undertreated endometriosis — distort tubo-ovarian relationships and impair fertility through mechanical obstruction and altered pelvic microenvironment. PEARS adhesiolysis principles emphasize meticulous sharp dissection, copious irrigation, and anti-adhesion adjuncts to restore normal anatomy and optimize postoperative fertility outcomes.

Chapter 81: Preventing Pelvic Adhesions

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Postoperative pelvic adhesions are a leading cause of secondary infertility, chronic pain, and bowel obstruction following gynecologic surgery, making adhesion prevention a primary surgical quality metric in NaProTECHNOLOGY. PEARS technique integrates continuous peritoneal irrigation, meticulous tissue handling, avoidance of foreign-body contamination, and selective use of barrier agents to minimize the fibrinous cascade that initiates adhesion formation.

Minimal surgery for the twisted ischaemic adnexa can preserve ovarian function

Oelsner G et al., 2003 · Human reproduction (Oxford, England)

Recently detorsion has replaced salpingo-oophorectomy as treatment for the twisted ischaemic adnexa. This paper asssess whether the ovary resumes normal function after preservation by detorsion. The results of detorsion performed between January 1988 and December 2001 were retrospectively analysed. Post-operative complications and subsequent ovarian function were assessed including: ultrasound monitoring of follicular development, adnexal appearance during subsequent surgery, and the outcome of IVF. A total of 102 detorsions were performed; 67 by laparoscopy, 35 by laparotomy. No patient developed thromboembolism. Post-operative fever occurred in 15% of patients after laparoscopy and 29% after laparotomy (P < 0.01). Patients were hospitalized for a mean (+/- SD) of 2.1 +/- 1.2 and 7.4 +/- 1.5 days after laparoscopy and laparotomy respectively (P < 0.001). Ultrasound showed normal follicular development in 93 and 91% of patients after detorsion by laparoscopy and laparotomy respectively. At subsequent surgery, the adnexa appeared normal in nine out of nine patients after laparoscopy and in four out of five patients after laparotomy. Four patients of the laparoscopy group and two patients of the laparotomy group underwent subsequent IVF. In all six patients oocytes retrieved from the previously ischaemic ovary were fertilized. Detorsion with adnexal sparing is the treatment of choice for twisted ischaemic adnexa, and preferably performed by laparoscopy.

Ovarian wedge resection by minilaparatomy in infertile patients with polycystic ovarian syndrome: a new technique

Yildirim M et al., 2003 · Eur J Obstet Gynecol Reprod Biol ·

To determine the effects of ovarian wedge resection by minilaparotomy in infertile patients with polycystic ovarian syndrome (PCOS). One hundred and thirty-four anovulatory patients with PCOS, who were previously treated with clomiphene citrate and gonadotropins and did not conceive were operated via minilaparotomy with microsurgical principles and ovarian wedge resection was performed on each subject. Pregnancy rates and adhesion formation were investigated retrospectively. A total of 121 pregnancies were achieved in 2 years (90%). One hundred and four patients conceived within the first 6 months (78%) and the remaining 17 patients conceived within 2 years (13%) following the operation. Sixty-eight patients had a second pregnancy later. In the post-operative period, 24 patients had cesarean delivery and 20 had diagnostic laparoscopy. Out of these 44 patients, only 5 of them were found to have minimal adhesions. This technique offers high pregnancy rates and minimal adhesion formation. Ovarian wedge resection by minilaparotomy might be an alternative treatment approach in patients with PCOS who did not conceive with standard ovulation induction protocols.

Avoidance of multiple pregnancies after ovulation induction by supernumerary preovulatory follicular reduction

Albano C et al., 2001 · Fertil Steril ·

To evaluate the effect of supernumerary preovulatory follicular reduction as an approach to avoid multiple pregnancies in ovulation induction or superovulation cycles. Retrospective study. Tertiary referral center. PATIENT(S): In 26 cycles, 24 patients underwent ovulation induction or superovulation with either clomiphene citrate or hMG. INTERVENTION(S): Selective follicle aspiration was performed before hCG administration. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate and numbers of multiple pregnancies. RESULT(S): A mean number of 4.5 follicles with a diameter > or =15 mm and a mean number of 4.5 follicles with a diameter < or =14 mm were observed before hCG administration. A mean number of 2.3 follicles with a diameter > or =15 mm and a mean number of 1.8 follicles with a diameter < or =14 mm were aspirated before the hCG administration. Seven singleton pregnancies (26.9% per cycle) ensued from the treatment. CONCLUSION(S): Aspiration of supernumerary follicles after ovulation induction or superovulation seems to be a valid approach to avoid multiple pregnancies without affecting pregnancy rate.

Requesting information about and obtaining reversal after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization

Schmidt JE et al., 2000 · Fertility and sterility

To determine the cumulative probabilities over 14 y of requesting information on sterilization reversal and of obtaining a reversal and to identify risk factors observable at sterilization for both measures of regret. The U.S. Collaborative Review of Sterilization, a prospective cohort study. Fifteen medical centers in 9 cities. 11,232 women. Cumulative probabilities of requesting information on reversal and undergoing reversal. The 14-y cumulative probability of requesting reversal information was 14.3% (95% confidence interval [CI], 12.4%-16.3%). Among women aged 18 to 24 y at sterilization, the cumulative probability was 40.4% (95% CI, 31.6%-49.2%). Women aged 18 to 24 y were almost 4 times as likely to request reversal information as were women > or = 30 years of age (adjusted rate ratio [RR], 3.5; 95% CI, 2.8-4.4). Number of living children was not associated with requesting reversal information. The overall cumulative probability of obtaining reversal was 1.1% (95% CI, 0.5-1.6). Younger women (18 to 30 y) were more likely to obtain reversal (RR, 7.6; 95% CI, 3.2-18.3). Women who were sterilized at a young age had a high chance of later requesting information about reversal, regardless of their number of living children.

Barrier agents for preventing adhesions after surgery for subfertility

Wiseman D et al., 2000 · Cochrane Database Syst Rev ·

Pelvic adhesions can be the result of inflamation, endometriosis or surgical trauma. Prevention of postoperative adhesions (either new or reoccurance) has been postulated by using barriers to prevent two surfaces being in contact. When pelvic surgery is being undertaken strategies to reduce pelvic adhesions occurring may be undertaken and these include barrier agents which are placed between the pelvic structures. Two synthetic barriers with differential characteristics are commercially available: oxidised regenerated cellulose (Interceed) and polytetrafluoroethylene (PTFC) (GoreTex). The objective of this review was to assess the effect of mechanical barriers (materials interposed between pelvic structures to prevent adherence of serosal surfaces) used during pelvic surgery in women of reproductive age on pregnancy rates, pelvic pain, or postoperative adhesion reformation. Search Strategy: The Cochrane Menstrual Disorders and Subfertility Group specialised register of controlled clinical trials was undertaken. In addition, companies were contacted for unpublished trials. Selection Criteria: Randomised controlled trials or controlled clinical trials of barriers versus no treatment or other barriers in women undergoing fertility preserving pelvic surgery. Reviewers assessed eligibility and trial quality. MAIN 15 randomised controlled trials were included. Five trials randomised patients while the remainder randomised pelvic organs. Laparoscopy was the primary surgical technique in six trials while the remaining trials were laparotomy. Indications for surgery included myomectomy (five trials), ovarian surgery (four trials), pelvic adhesions (six trials), endometriosis (two trials) and mixed (one trial). Thirteen trials assessed Interceed versus no treatment, two assessed Interceed versus Gore-Tex, one trial assessed Gore-Tex versus no treatment, and one trial assessed Seprafilm versus no treatment. No study reported pregnancy or reduction in pain as an outcome. The use of Interceed in women was associated with reduced incidence of pelvic adhesion formation, both new formation and re-formation following laparoscopic surgery and after laparotomy. Gore-Tex was more effective than no barrier or Interceed in preventing adhesion formation. There was limited evidence that Seprafilm was effective in preventing adhesion formation in women following myomectomy. REVIEWER'S The absorbable adhesion barrier Interceed reduces the incidence of adhesion formation, both new formation and re-formation, at laparoscopy and laparotomy, but there are insufficient data to support its use to improve pregnancy rates. Gore-Tex may be superior to Interceed in preventing adhesion formation but its usefulness is limited by the need for suturing and later removal. There was no evidence of effectiveness of Seprafilm in preventing adhesion formation.

The prognostic role of salpingoscopy in laparoscopic tubal surgery

Marana R et al., 1999 · Hum Reprod ·

The present study was designed to evaluate the prognostic value of salpingoscopy in patients undergoing tubal laparoscopic surgery for infertility due to periadnexal adhesion or distal tubal occlusion. In addition, the clinical value of salpingoscopy was compared with a current classification system of adnexal adhesions and distal tubal occlusion. A total of 51 patients with either adnexal adhesions (24 patients) or hydrosalpinx (27 patients) were prospectively evaluated. Salpingoscopy was performed concomitantly with salpingo-ovariolysis or salpingoneostomy at the time of operative laparoscopy. There was no significant correlation between salpingoscopic classes and the classification system used for both the salpingo-ovariolysis and the salpingoneostomy groups of patients. The patients had a mean follow-up of 33 months. Patients with a normal tubal mucosa (salpingoscopic classes I and II) had a 71% cumulative term pregnancy rate in the salpingo-ovariolysis group and a 64% cumulative term pregnancy rate in the salpingoneostomy group. No intrauterine pregnancies were obtained in patients with intratubal damage (salpingoscopic classes III to V). There was a statistically significant correlation between the occurrence of a term pregnancy and the salpingoscopic classes, but not with the classification system used. These results suggest that patients with tubal infertility should be offered operative laparoscopy with salpingoscopy as the first step of treatment.

Metaanalysis of the safety and efficacy of an adhesion barrier (Interceed TC7) in laparotomy

Wiseman DM et al., 1999 · J Reprod Med ·

To evaluate the safety and efficacy of an oxidized, regenerated, cellulose adhesion barrier (Interceed TC7) in the reduction of pelvic adhesions. Clinical studies published or completed by December 31, 1994, evaluating the barrier used at laparotomy were considered for a metaanalysis. Of 10 studies (n = 560) identified, data from 7 (n = 389) met the inclusion criteria for determining the reduction in the incidence of adhesions and 5 (n = 311) for determining the reduction in adhesion extent (raw surface area after adhesiolysis). There was a 24.2 +/- 3.3% difference in the incidence of adhesions (P < .001) between barrier-treated and untreated sites. Adhesion-free outcomes were 1.5-2.5 times more likely at barrier-treated sites than at sites with good surgical technique alone (odds ratio = 2.89; 95% confidence interval = 2.15-3.90). Barrier treatment resulted in a greater reduction (1.1 +/- 0.4 cm2) in adhesion extent (raw surface area) than good surgical technique alone (P < .001). Four adverse events were recorded; they were typical of those seen after surgery. No event was considered to be definitely related to the use of the barrier. The barrier significantly reduced the incidence and extent of adhesions as compared with no treatment, confirming the conclusion from individual studies that it is safe and effective in pelvic laparotomy surgery.

Pathophysiology and management of proximal tubal blockage

Honoré GM et al., 1999 · Fertil Steril ·

To review the physiology, pathology, and treatment of proximal tubal disease. Relevant reports on the pathophysiology of proximal tubal disease were reviewed. All studies in English of microsurgery and macrosurgery, and of radiographic and hysteroscopic cannulation in women with proximal tubal blockage were identified through MEDLINE searches. All studies of therapy for proximal blockage that included pregnancy rates were considered. Series of sterilization reversals, series of unilateral or combined procedures, and series in which the location of tubal blockage was not given were excluded from the data analyses. Raw data were assessed for homogeneity, then standardized and pooled. Total and ongoing pregnancy rates after microsurgery and macrosurgery, as well as radiographic and hysteroscopic transcervical cannulation, were compared by the chi2 test. Relative risks for total and ongoing pregnancies were calculated for all treatment methods. RESULT(S): This meta-analysis suggests that, overall, microsurgical anastomosis results in higher total and ongoing pregnancy rates than macrosurgery or radiographic tubal cannulation. However, pregnancy rates in selected series of transcervical tubal cannulation are similar to those reported for microsurgery. CONCLUSION(S): Ongoing intrauterine pregnancy rates near 50% can be achieved in patients with proximal blockage of the fallopian tube. Selective salpingography and transcervical cannulation under fluoroscopic guidance are effective at establishing patency in appropriately selected patients and are less invasive and costly than the surgical alternatives.

Laparoscopic fimbrioplasty: an evaluation of 35 cases

Audebert AJ et al., 1998 · Human reproduction (Oxford, England)

The aim of this prospective study was to assess the value of laparoscopic treatment of severe fimbrial occlusions. During a period of 52 months infertile patients with fimbrial lesions were treated by operative laparoscopy. Only those patients requiring incision of the tubal serosa (salpingostomy) were included, representing the most severe lesions. The most frequent cases, those patients requiring simple adhesiolysis and deagglutination of the fringes, were excluded. All tubal lesions were documented carefully. Positive Chlamydia trachomatis (CT) serology was found in 65.7% of the patients. All the patients were followed up for at least 2 years. Three patients lost to follow-up were defined as failures. The global conception rate was 74.3%. The intrauterine pregnancy rate was 51.4%, and the 'take home baby rate' was 37.1% (only the first pregnancy being taken into account). The ectopic pregnancy rate was 22.9%. A positive CT serology was found to have a significant influence on the outcome. It can be concluded that the laparoscopic approach provides results similar to those obtained by microsurgery for the treatment of severe fimbrial occlusions, and represents an acceptable alternative to in-vitro fertilization (IVF) in selected cases.

Laparoscopic fimbrioplasty and neosalpingostomy. Experience of the Yaoundé General Hospital, Cameroon (report of 194 cases)

Kasia JM et al., 1997 · European journal of obstetrics, gynecology, and reproductive biology

OBJECTIVE(S): To study the fertility results after laparoscopic distal tuboplasty and compare them with the data in the literature. 194 laparoscopic distal tuboplasties were carried out from May 1992 to May 1994 in the Yaounde General Hospital (Cameroon). The results were analysed according to the age of the patients, the type and duration of infertility, past history of abortion, laparotomy and Chlamydia trachomatis infection, the tube and adhesion scores, surgical procedures and achievement of pregnancy. The fertility rates were calculated according to Cramer's method [11]. The cumulative pregnancy rate curves were drawn up from the life table [12] and compared using the Log-Rank test. 53 patients obtained pregnancy (27.3%) of which 45 were inter-uterine (23.2%) and 8 ectopic (4.1%). Of the 45 intra-uterine pregnancies (IUP), 36 were obtained after fimbrioplasty (33.3%) and 9 after neosalpingostomy (10.5%). The monthly fertility rate at one year was 1.4%. The rate of IUP for tube stages I and II is significantly higher than that for stages III and IV (p<0.001). However the rate of ectopic pregnancies (EP) is proportional to damage to the tubes. Infection with Chlamydia trachomatis, and residual inflammation could have an effect on the achievement of pregnancy. CONCLUSION(S): Our results are similar to those found in the literature. The tube stage thus remains the decisive factor in terms of fertility (Cox: p<0.001). Operative laparoscopy is the best alternative in our countries compared with laparotomy for distal tubal pathology.

Pregnancy outcome after laparoscopic fimbrioplasty in nonocclusive distal tubal disease

Saleh WA et al., 1997 · Fertility and sterility

To determine pregnancy rates (PR) after fimbrioplasty and salpingostomy in nonocclusive distal tubal disease. To evaluate the relative impact of various factors using contemporary statistical analysis. Prospective cohort. Tertiary institutional infertility clinic. PATIENTS(S): Infertility patients. INTERVENTION(S): Fimbrioplasty and salpingostomy. MAIN OUTCOME MEASURE(S): Cumulative PR, monthly fecundity rates, monthly probability of pregnancy, crude PR, and cure rates. RESULTS(S): Thirty-five percent of patients conceived with a cure rate of 72.2%, monthly probability of pregnancy of 3.9%, and monthly fecundity rate of 3.9%. Cumulative PRs were 22%, 35%, and 58% at 6, 12, and 24 months, respectively. Pairwise comparisons (unilateral, bilateral, or either) failed to detect any statistical difference between the salpingostomy and fimbrioplasty groups. Salpingostomy patients initially may have a higher tendency to become pregnant but appear to lose that advantage after the first few months. When patients with tubo-ovarian adhesions are excluded from the analysis, patients who underwent a bilateral salpingostomy as their sole procedure had better outcome compared with those who only underwent bilateral fimbrioplasty. There was no significant association between pregnancy outcome and the presence of endometriosis, other infertility factors, or tubo-ovarian adhesions. The staging of adnexal adhesions and endometriosis did not predict pregnancy outcome. CONCLUSION(S): Laparoscopic fimbrioplasty and salpingostomy are clinically efficacious for the treatment of nonocclusive distal tubal disease. After accounting for statistical interactions of various factors among them, no particular association with pregnancy outcome could be identified. This illustrates the need for a revision of the classification of patients with distal tubal disease.

Reduction of adhesions after uterine myomectomy by Seprafilm membrane (HAL-F): a blinded, prospective, randomized, multicenter clinical study. Seprafilm Adhesion Study Group

Diamond MP, 1996 · Fertil Steril ·

To assess the safety and efficacy of Seprafilm (HAL-F), Bioresorbable Membrane, (Genzyme Corporation, Cambridge, MA) in reducing the incidence, severity, extent, and area of uterine adhesions after myomectomy. Prospective, randomized, blinded, multicenter study. Adhesion reduction was assessed by an independent, blinded, gynecologic surgeon who reviewed videotapes of each patient's second-look laparoscopy. Nineteen institutions across the United States. PATIENT(S): One hundred twenty-seven women undergoing uterine myomectomy with at least one posterior uterine incision > or = 1 cm in length. INTERVENTION(S): Patients were randomized to treatment with Seprafilm or to no treatment at the completion of the myomectomy. MAIN OUTCOME MEASURE(S): The incidence, severity, extent, and area of uterine adhesions at second-look laparoscopy. RESULT(S): The incidence, measured as the mean number of sites adherent to the uterine surface, was significantly less in treated patients (4.98 +/- 0.52 [mean +/- SEM] sites) than in no treatment patients (7.88 +/- 0.48 sites) as were the mean uterine adhesion severity scores (1.94 +/- 0.14 versus 2.43 +/- 0.10; treatment versus no treatment, respectively), mean extent scores (1.23 +/- 0.12 versus 1.68 +/- 0.10), and mean area of adhesions (13.2 +/- 1.67 versus 18.7 +/- 1.66 cm2). No adverse events occurred that were judged to be related to the use of Seprafilm. CONCLUSION(S): In this multicenter study, treatment of patients after myomectomy with Seprafilm significantly reduced the incidence, severity, extent, and area of postoperative uterine adhesions. Additionally, Seprafilm treatment was not associated with an increase in postoperative complications.

Prevention of de-novo adhesion formation after laparoscopic myomectomy: a randomized trial to evaluate the effectiveness of an oxidized regenerated cellulose absorbable barrier

Mais V et al., 1995 · Hum Reprod ·

To evaluate the effectiveness of the oxidized regenerated cellulose absorbable barrier (Interceed, TC7) in the prevention of de-novo adhesion formation after laparoscopic myomectomy, a prospective and randomized study was performed at the Department of Obstetrics and Gynaecology of the University of Cagliari, Cagliari, Italy. A total of 50 pre-menopausal non-pregnant women, aged 23-42 years, who submitted to laparoscopic myomectomy from January 1993 to June 1994, were randomized to surgery alone (control group, n = 25) or surgery and oxidized regenerated cellulose barrier (Interceed group, n = 25). Neither group received any other treatment for adhesion prevention. A second-look laparoscopy was performed 12-14 weeks after laparoscopic myomectomy. The incidence of adhesion-free patients was assessed at second-look laparoscopy by an investigator not informed of the treatment. The numbers of adhesion-free patients were three out of 25 (12%) in the control group and 15 out of 25 (60%) in the treatment group (P < 0.05). In conclusion, the oxidized regenerated cellulose absorbable barrier significantly reduced de-novo adhesion formation after laparoscopic myomectomy.

Correlation between the American Fertility Society classifications of adnexal adhesions and distal tubal occlusion, salpingoscopy, and reproductive outcome in tubal surgery

Marana R et al., 1995 · Fertil Steril ·

To compare the prognostic value of salpingoscopy with a current classification system of adnexal adhesions and distal tubal occlusion in patients with tubal infertility undergoing reconstructive tubal surgery. Prospective clinical study. Department of Obstetrics and Gynecology of the Catholic University, a tertiary care University Center in Rome, Italy. Fifty-five infertile patients with either adnexal adhesions (29 patients) or hydrosalpinx (26 patients) undergoing reconstructive tubal surgery. Salpingoscopy performed concomitantly to salpingo-ovariolysis or salpingoneostomy at the time of either operative laparoscopy or laparotomy using microsurgical techniques. Salpingoscopic findings were compared with a current classification system of adnexal adhesions and distal tubal occlusion. The patients were followed for a mean follow-up of 49 months; the pregnancy rates achieved were correlated with the salpingoscopic findings and the classification system used. There was a significant correlation between the salpingoscopic grade and the occurrence of a term pregnancy for both the salpingo-ovariolysis and salpingoneostomy groups of patients. There was no significant correlation between the classification system used and the occurrence of a term pregnancy for both groups of patients. Salpingoscopy plays an important role in selecting the patients who may benefit the most from reconstructive tubal surgery.

Tubal cannulation

Valle RF, 1995 · Obstetrics and Gynecology Clinics of North America

While uterotubal chromopertubations were performed early in the 1970s with the introduction of hysteroscopy, cornual cannulation was extended and adapted to fluoroscopy. The disadvantages of fluoroscopy include the difficulty in ruling out tubal spasm, inability to evaluate distal tubal disease, and other pelvic abnormalities. Tubal cannulation has emerged as an excellent alternative to treat patients with cornual obstruction. Only those patients in whom cannulation fails should be subjected to microsurgical reconstruction. While cannulation with coaxial catheters began under fluoroscopy, the use of the hysteroscope simplifies the technique. With laparoscopy the hysteroscopic approach enables tubal cannulation and evaluation of the entire pelvis. Treatment of additional problems affecting the fallopian tubes, particularly adhesions and endometriosis, is possible. Laparoscopy helps in monitoring the procedure and visual assessment of tubal patency. The ability to observe the uterotubal junctions directly by hysteroscopy provides an excellent approach for tubal cannulation. There are two techniques to cannulate the fallopian tubes, either with coaxial catheters or catheters with distal balloons, but the result obtained with these two techniques is similar. The simplicity of coaxial catheters makes this approach more appealing, and with the hysteroscope one can avoid exposure to radiation. The results obtained with tubal cannulation are encouraging and this procedure should be offered as the initial method to attempt treatment of tubal cornual obstruction. Often it can represent an excellent alternative to microsurgical tubal anastomosis, avoiding a laparotomy and extended disability.

Reduction of ovarian adhesions by the use of Interceed. Ovarian Adhesion Study Group

Franklin RR, 1995 · Obstet Gynecol ·

To evaluate the efficacy of Interceed (TC7) Absorbable Adhesion Barrier, an oxidized regenerated cellulose fabric, as a barrier to the development of postsurgical ovarian adhesions after surgery involving the ovaries. In a multicenter randomized study, 55 patients with bilateral ovarian disease were treated at initial laparotomy. At the end of the procedure, one ovary was assigned randomly to be wrapped with Interceed and the other was left uncovered. A second-look laparoscopy was performed 10-98 days later to evaluate the occurrence and severity of adhesions and the raw ovarian surface area exposed after lysis of adhesions. At second-look laparoscopy, 26 of 55 Interceed-treated ovaries were free of adhesions, compared with 14 of 55 untreated control ovaries, a statistically significant difference (P = .028, Fisher exact test). At second-look laparoscopy, ovaries treated with Interceed formed adhesions less extensively (1.66 +/- 0.34 cm2) than did untreated ovaries (2.75 +/- 0.60 cm2) and with a greater reduction of raw ovarian surface area (difference in area differential -1.89 +/- 0.96 cm2; P = .055, paired t test). Adhesion scores at second-look laparoscopy were reduced significantly for ovaries treated with Interceed compared with untreated ovaries (P = .02, Wilcoxon signed-rank test). No adverse events were recorded during the course of the study. Treatment of ovaries with Interceed significantly reduced the occurrence and severity of postsurgical ovarian adhesions.

Laparoscopic implant of Gore-Tex surgical membrane

Crain J et al., 1995 · J Am Assoc Gynecol Laparosc ·

One of the major postoperative complications of reproductive surgery is the formation of adhesions. 1, 2 Over the past several decades a number of methods have been explored to solve this problem, g, 4 Recently there has been renewed interest in covering the damaged peritoneal surface with an absorbable or nonabsorbable barrier as a means of preventing adhesions after fertility-enhancing surgery. Currently, two barriers are commercially available for clinical use: Interceed Absorbable Adhesion Barrier (Ethicon, Somerville, NJ), which is composed of oxidized regenerated cellulose, and the Gore-Tex Surgical Membrane (W. L. Gore & Associates, Inc., Flagstaff, AZ), constructed of expanded polytetrafluoroethylene (e-PTFE). Interceed has been investigated both experimentally and clinically and has proved effective in some circumstances. 5,6 Studies also report on the laparoscopic application of Interceed in fertility-enhancement procedures.7, 8 Recent reports, however, have questioned the product's degree of effectiveness and raised concern about possible residual effects it may have on peritoneal tissue? 11 Gore-Tex Surgical Membrane has been indicated for use in peritoneal reconstruction since 1983, and experimental and clinical reports describe its effectiveness in preventing adhesion formation. 12-14 Interceed is an absorbable material that is phagocytized by macrophages within 1 month. Gore-Tex Surgical Membrane is nonabsorbable and is intended to be a permanent implant. Since all published reports on the clinical application of the Gore-Tex membrane discuss implantation by laparotomy, ~g, 14 the ease of use of this product in laparoscopic surgery is of particular interest. Moreover, because of its permanence, its long-term safety and effectiveness merit examination. A prospective, multicenter clinical study was undertaken to evaluate the ease of using Gore-Tex Surgical Membrane laparoscopically.

Expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane) is superior to oxidized regenerated cellulose (Interceed TC7+) in preventing adhesions

Haney AF et al., 1995 · Fertil Steril ·

To compare the impact of expanded polytetrafluoroethylene (PTFE; Gore-Tex Surgical Membrane; W. L. Gore & Associates, Inc., Flagstaff, AZ) and oxidized regenerated cellulose (Interceed TC7, Johnson & Johnson Medical, Inc., Arlington, TX) on the development of postsurgical adhesions. A multicenter, nonblinded, randomized clinical trial. University medical centers. Each barrier was allocated randomly to the left or right sidewall of every patient. Thirty-two women with bilateral pelvic sidewall adhesions undergoing reconstructive surgery and second-look laparoscopy. Adhesion score (on a 0- to 11-point scale), the area of adhesion (cm2), and the likelihood of no adhesions. The use of both barriers was associated with a lower adhesion score and area of adhesion postoperatively. However, those sidewalls covered with PTFE had a significantly lower adhesion score (0.97 +/- 0.30 versus 4.76 +/- 0.61 points, mean +/- SEM) and area of adhesion (0.95 +/- 0.35 versus 3.25 +/- 0.62 cm2). Overall, more sidewalls covered with PTFE had no adhesions (21 versus 7) and, when adhesions were present on the contralateral sidewall, the number of sidewalls covered with PTFE without adhesions was greater than those covered with oxidized regenerated cellulose (16 versus 2). Expanded polytetrafluoroethylene was associated with fewer postsurgical adhesions to the pelvic sidewall than oxidized regenerated cellulose.

The efficacy of Interceed(TC7)* for prevention of reformation of postoperative adhesions on ovaries, fallopian tubes, and fimbriae in microsurgical operations for fertility: a multicenter study. Nordic Adhesion Prevention Study Group

Nordic Adhesion Prevention Study Group, 1995 · Fertil Steril ·

To evaluate the efficacy of Interceed as an adjuvant in the prevention of postoperative adhesion reformation to the ovary, fallopian tube, and fimbria when used together with microsurgical techniques. Prospective, randomized, multicenter, controlled clinical study. Normal human volunteers in an academic research environment. Sixty-six women suffering from infertility due at least in part to bilateral tubal disease with bilateral adhesions attached to ovaries, fallopian tubes, and fimbriae. Adhesiolysis bilaterly through laparotomy with microsurgical techniques, application of Interceed on one of the sides randomly assigned not known by the surgeon before application, follow-up laparoscopy 4 to 10 weeks postoperatively, with each patient serving as her own control. Adhesion severity scores at all sites and number of adhesion free organs after laparotomy and follow-up laparoscopy. When the initial scores registered at the operation for fertility were compared with those registered at the second-look laparoscopy, the results indicated that gentle microsurgical techniques resulted in a significant reduction of postoperative adhesions. Adnexa, which were covered with Interceed, had significantly lower adhesion scores than the control adnexa, representing an improvement of 39% compared with microsurgery alone (control) in reducing adhesion reformation scores. When combined with microsurgical techniques, Interceed reduced adhesion reformation scores by 70%. The number of ovaries, fallopian tubes, and fimbriae without adhesions at the time of second-look laparoscopy was significantly increased by approximately twofold when organs were covered with Interceed. In a prospective, randomized, multicenter, controlled clinical study using a protocol in which other adjuvants have been shown not to be efficacious, Interceed was shown to reduce significantly the incidence and severity of adhesion reformation to the ovary, fallopian tube, and fimbria after infertility surgery.

An expanded polytetrafluoroethylene barrier (Gore-Tex Surgical Membrane) reduces post-myomectomy adhesion formation. The Myomectomy Adhesion Multicenter Study Group

Myomectomy Adhesion Multicenter Study Group, 1995 · Fertil Steril ·

To evaluate the effects of the expanded polytetrafluoroethylene barrier (PTFE), Gore-Tex Surgical Membrane, in reducing postmyomectomy adhesion formation. Multicenter randomized clinical trial. Twenty-seven women having myomectomy with at least two incisions on the uterine fundus and posterior uterine wall of similar length were enrolled in the study. At laparotomy, the two incision sites were randomly assigned to be covered with PTFE or were left uncovered. A second-look laparoscopy to evaluate adhesion formation and to lyse adhesions was done from 2 to 6 weeks after the myomectomy. Adhesions were scored using a 0- to 11-point scoring system. At laparoscopy, 15 of 27 incisions covered with PTFE (55.6%) and only 2 of 27 uncovered sites (7.4%) were completely free of adhesions. The mean adhesion score at the PTFE sites was significantly lower (1.88 +/- 0.46; SEM) than at the control sites (7.55 +/- 0.57). The PTFE barrier is effective in reducing postmyomectomy adhesion formation.

Further Evaluation of Uterine Isolation

Hilgers TW, 1994 · Linacre Q ·

"Uterine Isolation" has been discussed, in one form or another, since the early 1940's by such notable American theologians as Fr. John C. Ford, SJ, Fr. Gerald Kelly, SJ; Fr. Francis J. Connell, C.SS.R.; Fr. L. Bender; Fr. John R. Connery; SJ, Fr. Edwin F. Healy, SJ; and Fr. Thomas J. O'Donnell, SJ.l The term "uterine isolation" originated with Fr. O'Donnell. O'Donnell, who is personally convinced of the validity of the arguments for the solid probability of the "uterine isolation" view, was also responsible for having this deleted from the "Ethical and Religious Directives for Catholic Health Facilities" which were published and approved by the bishops in 1971." 'Isolation of the uterus' or 'uterine isolation' " he says, "had taken root in the medical-moral community and, either through misunderstanding or deception, was being used as a presumably morally acceptable semantic for various forms of clearly contraceptive sterilization."l O'Donnell states that the following three points need to be understood by Catholic hospital administration and staff with regard to the term "uterine isolation procedure": 1. Hysterectomy in the presence of a uterus which has been so damaged or weakened by multiple cesarean sections that it is judged to be incapable (because of the damage within the uterus itself) of safely supporting another pregnancy is, with solid probability, not a contraceptive sterilization and is permitted . . . 2. In this case, and only in this case, the isolation of such a uterus at its tubal adnexa, instead of its extirpation, if clinically indicated, is, with solid probability, not a contraceptive sterilization and thus may be permitted and practiced; unless, of course, this is disapproVed by the bishop of the diocese who might well foresee greater harm in the danger of misunderstanding and morally unwarranted extension of the procedure as a semantic to conceal directly contraceptive sterilizations. 3. If, after further study and investigation, there would be a sufficient consensus of theological opinion or a decision by the Congregation for the Doctrine of the Faith that either of the procedures described above (either the hysterectomy in this case or the isolation procedure) is indeed a direct sterilization (such as to discount the solid probability that it is not), then neither of the procedures could be done within the context of Catholic teaching. The sale moral defense of either procedure is the solid probability of the moral opinion that it is not a directly contraceptive sterilization (emphasis applied). I wish to emphasize the need for further study and investigation of this issue because the experience with "uterine isolation" is compelling and proves that the practice is nothing but direct contraceptive sterilization. It is also a practice with inappropriate medical justification . . . a practice which, in the 1990's, cannot be justified on medical moral grounds. One of the most important questions that needs to be asked with regard to "uterine isolation" is "What are we isolating the uterus from?" It is clear that the uterus is not being isolated from either the sperm or the ovum since they present no potential of risk. It is equally clear that the isolation of the uterus, so proposed, is not isolating the uterus from any known disease condition. the only possible thing that this procedure could be isolating the uterus from is a pregnancy . Thus, it seems equally clear that the primary intent of such a "uterine isolation" is contraceptive sterilization. Furthermore, the actual application of "uterine isolation" policies in Catholic hospitals suggests that it is direct contraceptive sterilization.

Contemporary adhesion prevention

diZerega GS, 1994 · Fertil Steril ·

To (1) review the events leading to peritoneal adhesion formation; (2) review traditional adhesion prevention adjuvants; (3) overview studies for adhesion prevention barriers including a perspective for their use; and (4) look toward the future of adhesion prevention. A great deal of effort has been dedicated to reduce adhesion formation because of the morbidity associated with adhesions and the associated economic burden, which considering only hospital costs and surgeons' fees, was $1,180 million in the United States. To understand the role of adhesion barriers in gynecological surgery, an appreciation of the cellular cascade and temporal nature of peritoneal repair is necessary. Evidence indicates that areas denuded of peritoneum will heal satisfactorily and that suturing of the peritoneum may increase adhesion formation. Physical barriers, including both mechanical and viscous solutions, are widely used to prevent adhesion formation by limiting tissue apposition during the critical stages of mesothelial repair. Clinical studies do not support the use of intraperitoneal, dextran for adhesion prevention. Theoretical considerations of peritoneal fluid dynamics indicate that crystalloid instillates should not prevent adhesion formation because of their short intraperitoneal residence. This prediction is consistent with clinical observation. The availability of Interceed (Johnson and Johnson Medical, Inc., Arlington, TX) and Gore-Tex Surgical Membrane (W.L. Gore, Flagstaff, Arizona) barriers provides substantial progress in postsurgical adhesion prevention. Although many investigators are incorporating adhesion prevention barriers into their routine clinical situations, physician acceptance is constrained by technical difficulties.

Transcervical fallopian tube catheterization and recanalization for proximal tubal obstruction

Thompson KA et al., 1994 · Fertil Steril ·

To evaluate further the safety and efficacy of selective ostial salpingography combined with transcervical wire recanalization for the diagnosis and treatment of proximal tubal obstruction. Prospective study. Division of Reproductive Endocrinology and Department of Radiology at Harbor-University of California Los Angeles (UCLA) Medical Center, a tertiary care academic institution. Twenty-eight infertile patients diagnosed with proximal tubal obstruction by hysterosalpingogram (HSG) or by chromopertubation at laparoscopy (total of 46 obstructed tubes). After antibiotic prophylaxis and IV analgesia a conventional HSG was performed. If proximal tubal obstruction was confirmed, selective salpingography was done under fluoroscopic guidance. If proximal tubal obstruction was still present, wire recanalization using a new prototype cannula was then performed. If recanalization was successful, contrast media was injected to confirm tubal patency. Proximal tubal patency, complete tubal patency, pregnancies. Eleven of 46 tubes (23.9%) were patent by HSG. Ostial salpingography of the remaining 35 tubes revealed 6 patent tubes (13%). Nine of the 29 obstructed tubes (31%) had successful wire recanalization, and 8 of these were patent distally. There were 4 intrauterine pregnancies (IUPs) and 1 ectopic pregnancy after recanalization and 2 IUPs after ostial salpingography. Selective salpingography should be considered at the time of an HSG showing proximal tubal obstruction. If indicated, wire recanalization can also be attempted. Selective ostial salpingography combined with wire recanalization is a safe and effective procedure for the diagnosis and treatment of PTO.

Expanded-polytetrafluoroethylene but not oxidized regenerated cellulose prevents adhesion formation and reformation in a mouse uterine horn model of surgical injury

Haney AF et al., 1993 · Fertil Steril ·

To evaluate the ability of the two currently available surgical barriers, oxidized regenerated cellulose and expanded-polytetrafluoroethylene (PTFE), to prevent postsurgical adhesions. Murine uterine horns were approximated in the midline and the contacting uterine surfaces injured by electrocautery, cutting, and scratching, with and without barriers interposed. Sham-operated and experimental animals had adhesions assessed visually and histologically 7 days postoperatively. In another group, adhesions were created and then lysed 7 days later with barriers interposed. Readhesion formation was assessed 14 days after lysis with the PTFE being removed 7 days after lysis. Research laboratory Adhesions occurred at 58.5% of the electrocautery sites without barriers, 100% of the readhesion sites with recautery for hemostasis, and 92% of the recautery sites without hemostasis. None of the sham-operated sites developed adhesions. When oxidized regenerated cellulose was interposed, adhesions were observed at 36% of uninjured uterine horn sites, 62% with single and 92% with double electrocautery injuries and 90% of the reformation sites. The PTFE did not cause adhesions in uninjured controls and completely prevented adhesion formation and reformation, regardless of the type of injury or whether hemostasis was achieved. A thin cellular membrane, continuous with the uterine serosa, enveloped the PTFE. Expanded-polytetrafluoroethylene, but not oxidized regenerated cellulose, prevents adhesion formation and reformation in this murine uterine horn model. Additionally, oxidized regenerated cellulose was adhesiogenic even without surgical injury.

Selective salpingography and fluoroscopic transcervical salpingoplasty for diagnosis and treatment of proximal fallopian tube occlusions

Mårtensson O et al., 1993 · Acta Obstet Gynecol Scand ·

In 25 women with primary or secondary infertility, primary hysterosalpingography (HSG) or laparoscopy with chromopertubation indicated 33 proximal and 2 distal tubal obstructions. Four salpingectomies had been performed earlier. All patients were considered for transcervical catheter salpingoplasty (TCSP) to reconstruct tubal patency. Secondary examination with repeat HSG or selective osteal salpingography confirmed 26 proximal and 3 distal tubal occlusions while 17 tubes were patent. Selective osteal salpingography was performed successfully in 32 of 33 (97%) tubes. Sixteen of 26 (61.5%) proximally occluded tubes were successfully recanalized by coaxial catheter and guidewire technique while two of three distally occluded tubes were reopened by forceful flushing of contrast medium. So far, one ectopic and five intrauterine pregnancies were achieved in ten patients with observation time more than four months. Three patients have had normal deliveries. The favorable results, lack of complications and low costs seem to justify the recommendation to use selective salpingography and fallopian tube recanalization as the first intervention in patients with obstruction of the proximal fallopian tube.

Microsurgery alone or with INTERCEED Absorbable Adhesion Barrier for pelvic sidewall adhesion re-formation. The INTERCEED (TC7) Adhesion Barrier Study Group II

Azziz R, 1993 · Surg Gynecol Obstet ·

Adhesion re-formation after a reproductive operation, particularly involving the pelvic sidewall, is a prominent cause of failure in the surgical treatment of infertility. This study was done to evaluate the impact of standard microsurgery through laparotomy and the additional benefit of an oxidized regenerated cellulose adhesion barrier (INTERCEED [TC7] Absorbable Adhesion Barrier [Ethicon Inc.]), in reducing pelvic sidewall adhesion re-formation. One hundred and thirty-four patients with bilateral pelvic sidewall adhesions undergoing adhesiolysis by standard microsurgical techniques through laparotomy were treated during a prospective randomized trial involving 13 centers. After adhesiolysis, the deperitonealized surface of one pelvic sidewall was randomly assigned to be covered with INTERCEED Barrier, the contralateral sidewall serving as control. A second-look laparoscopy was performed ten days to 14 weeks postoperatively. Microsurgical adhesiolysis alone resulted in 24 percent of the sidewalls becoming free of adhesions and a 55.6 percent reduction in the area of adherent peritoneum. With microsurgery alone, 60 and 39 percent of adhesions initially characterized as filmy or severe, respectively, were not seen at second-look laparoscopy. The use of INTERCEED Barrier increased the incidence of adhesion-free sidewalls twofold. The treatment was also associated with a statistically significant reduction in the area of peritoneum affected by adhesion re-formation, compared with the control wall. Of the adhesions originally graded as severe, 61 percent of those treated with INTERCEED Barrier did not re-form at all. When evaluated on filmy adhesions, the use of the barrier was associated with a 72 percent reduction in adhesion re-formation. A measurable reduction in adhesion re-formation was found, depending on the initial adhesion type, with microsurgery alone. The addition of INTERCEED Barrier further reduced the incidence, extent and severity of postoperative adhesion re-formation. In this study, 90 percent of the patients benefited from the use of INTERCEED Barrier.

Transcervical tubal cannulation, past, present, and future

Risquez F et al., 1993 · Fertil Steril ·

To evaluate publications that introduced novel diagnostic and therapeutic transcervical procedures on the fallopian tubes. Major studies that conceptually changed the therapeutic approach to the fallopian tubes were reviewed. Minor publications were also included if they introduced a new concept or contributed to the topic. Clinical publications were selected if they involved transcervical diagnosis and treatment of fallopian tubes. Transcervical tubal catheterization procedures for diagnosis of tubal disease, tubal obliteration, tubal recanalization, and tubal medication are minimally invasive procedures that can improve our understanding and diagnostic accuracy of tubal disease. These procedures allow transcervical treatment of proximal tubal occlusion. Further improvements in equipment and methodology are promising. Transcervical tubal occlusion, gamete and embryo deposition, and treatment of ectopic pregnancy may all be performed using the transcervical approach. Transcervical tubal catheterization can replace microsurgery and IVF in selected patients with proximal tubal occlusion, improve the diagnostic accuracy of tubal disease, and deliver medications to the fallopian tubes. Cumulative knowledge suggests that transcervical tubal catheterization should become a universally accepted, taught, and practiced approach in the diagnosis and treatment of the fallopian tubes.

Adhesion formation after laparoscopic electrocoagulation of the ovarian surface in polycystic ovary patients

Naether OG et al., 1993 · Fertil Steril ·

To evaluate the incidence and extent of periovarian adhesion formation subsequent to laparoscopic electrocoagulation of the ovarian surface in infertility patients with polycystic ovarian disease (PCOD). From a total of 199 PCOD patients treated with ovarian electrocautery, 50 cases of laparoscopy and 12 cesarean sections served as second-look investigation. A subgroup of 30 patients had abdominal lavage and artificial ascites after surgery; they underwent "early" second-look (2 to 14 days after laparoscopy). All patients were referred to our fertility outpatient clinic affiliated with the university hospital. Infertility patients with polycystic ovarian reaction to hormonal stimulation therapy underwent laparoscopic electrocoagulation of the ovarian surface. Adhesion formation was detected in 19.3%; the incidence reduced to 16.6% with the use of abdominal lavage. The adhesions found were obviously due to bleeding of the ovarian capsule caused by electrocautery. Adhesiolysis was easily possible during "early" second-look. The incidence of de novo adhesion formation caused by laparoscopic electrocoagulation of the ovarian surface seems to be lower than after ovarian wedge resection; it can be reduced by abdominal lavage and artificial ascites.

Laparoscopic electrocoagulation of the ovarian surface in infertile patients with polycystic ovarian disease

Naether OG et al., 1993 · Fertil Steril ·

To assess the endocrinologic and clinical outcome after laparoscopic ovarian electrocautery because of polycystic reaction to ovarian stimulation in anovulatory infertility patients. Between 1986 and 1989, 133 patients with polycystic ovarian disease underwent laparoscopic electrocoagulation of the ovarian surface in an outpatient clinic after conventional ovarian stimulation had led to polycystic reaction. All patients were referred to our outpatient clinic affiliated with the university hospital. The reduction of androgen levels and normalization of cycle length were highly significant. The overall pregnancy rate was 70% (73 of 104), ranging from 27% in smokers to 94% in nonsmoking couples. In 26 second-look operations de novo adhesions were found in 26.9% of the patients. Laparoscopic coagulation of the ovarian surface is an effective tool to reduce elevated androgen levels and to improve the intraovarian mechanism of selecting a dominant follicle. A postoperative complication may be adhesion formation.

Evaluation of sodium carboxymethylcellulose for prevention of adhesions after uterine trauma in ewes

Moll HD et al., 1992 · Am J Vet Res ·

Efficacy of a 1% solution of sodium carboxymethylcellulose (CMC) infused into the peritoneal cavity of ewes was evaluated for prevention of intraperitoneal adhesions resulting from surgery of the reproductive tract. Six ewes were assigned to each of 4 groups. Group-1 ewes were controls that underwent ventral midline celiotomy and exploration of the abdominal viscera. Group-2 ewes were treated similarly to group-1 ewes, except that a 1% solution of CMC (14 ml/kg of body weight) was infused into the peritoneal cavity. This group was studied to determine whether CMC would cause changes in the peritoneal cavity. Group-3 comprised ewes representing a uterine trauma model. Ewes underwent abdominal exploration, but in addition had a standard embryo collection technique performed on 1 uterine horn and hysterotomy performed on the opposite uterine horn. Group-4 ewes were treated like group-3 ewes, except that, similar to treatment of group-2 ewes, CMC was infused into the peritoneal cavity. All ewes were euthanatized and necropsied 12 to 14 days after surgery. Abdominal adhesions were evaluated, and an adhesion severity score was assigned to each ewe on the basis of number and severity of the adhesions. Ewes of all groups had abdominal adhesions. Significantly (P less than 0.05) lower adhesion score was observed in ewes given CMC (groups 2 and 4) than in the adhesion model (group 3). Significant difference was not observed in adhesion score when groups 1, 2, or 4 were compared. Though not statistically significant, fewer adhesions were observed in ewes of groups 2 and 4 than in group-1 ewes.

Myomectomy for fertility enhancement and preservation

Verkauf BS, 1992 · Fertil Steril ·

To review, evaluate, and synthesize current published reports assessing the value of abdominal myomectomy in infertile women and those desiring to preserve fertility potential. Major studies dealing with myomectomy were identified through Medline Searches. Those papers reporting the results of myomectomy, factors influencing them, and potential future innovations were obtained. More than half of women not previously pregnant and undergoing myomectomy to preserve childbearing capacity for treatment of recurrent pregnancy wastage or previous infertility conceive. The long duration of infertility before surgery, absence of other factors to explain their not conceiving, and short time interval subsequent to surgery in which conception occurs suggests myomectomy has value in treatment of patients with leiomyomata and otherwise unexplained infertility. The operation carries acceptable risk. Approximately 25% of women undergoing myomectomy have recurrent leiomyomata, but most recurrences are sufficiently delayed to allow adequate opportunity for conception. Abdominal myomectomy is an appropriate alternative to hysterectomy for most women who wish to preserve childbearing potential or enhance it. For the future, myomectomy by endoscopic techniques may hold similar potential.

Comparison of the peritoneal cells elicited by oxidized regenerated cellulose (Interceed) and expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane) in a murine model

Haney AF et al., 1992 · Am J Obstet Gynecol ·

The peritoneal fluid cell responses to the available barriers used to prevent postoperative adhesions, oxidized regenerated cellulose (interceed) and expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane), were compared. Oxidized regenerated cellulose and expanded polytetrafluoroethylene were inserted into the peritoneal cavity of mice and the peritoneal fluid cell number, differential cell count, morphologic type, adherence to plastic, and phorbol-12,13-myristate acetate-stimulated hydrogen peroxide production evaluated. Peritoneal fluid cell attachment to oxidized regenerated cellulose and expanded polytetrafluoroethylene was evaluated by electron microscopy. Oxidized regenerated cellulose promptly elicited increased numbers of large, morphologically activated peritoneal fluid macrophages that adhered more rapidly and produced more hydrogen peroxide than controls. Expanded polytetrafluoroethylene gradually increased the number of normal-appearing peritoneal fluid macrophages with increased hydrogen peroxide production but normal adherence. Macrophages rapidly attached to both materials in vivo, with oxidized regenerated cellulose being rapidly degraded. Oxidized regenerated cellulose, to a greater extent than expanded polytetrafluoroethylene, elicits an acute peritoneal fluid inflammatory exudate in the mouse, which may contribute to the oxidized regenerated cellulose-induced peritoneal injury and de novo adhesions observed in this model.

Prophylaxis of pelvic sidewall adhesions with Gore-Tex surgical membrane: a multicenter clinical investigation. The Surgical Membrane Study Group

Surgical Membrane Study Group, 1992 · Fertil Steril ·

Eight patients with extensive adhesions and 10 undergoing myomectomy had Gore-Tex surgical membranes placed to prevent adhesion formation/reformation. At the time of second-look laparoscopy, the membranes were removed easily, and the extent of adhesion was minimal. Further studies are ongoing to validate these findings and to compare the Gore-Tex surgical membrane with antiadhesion agents.

Endoscopic carbon dioxide laser ovarian wedge resection in resistant polycystic ovarian disease

Ostrzenski A, 1992 · Int J Fertil ·

Clomiphene citrate therapy has been found to improve the infertility rate in women suffering from polycystic ovarian disease (PCOD). However, there still exists a group of women with PCOD who fail to respond to clomiphene citrate or human menopausal gonadotropin/human chorionic gonadotropin or urofollitropin/chorionic gonadotropin treatment, an ovarian wedge resection by laparotomy approach which has been known for 50 years. Within the last decade, translaparoscopic electrocautery and laser drilling techniques have been utilized. In 1986, a translaparoscopic carbon dioxide laser ovarian wedge resection was introduced for resistant PCOD. This paper describes the surgical principle of a translaparoscopic carbon dioxide laser ovarian wedge resection. This type of treatment results in a 75% crude conception rate, with a 67% rate of healthy live birth. There was an 8% postsurgical adhesion rate among 12 cases that were incorporated into the study. This mode of therapy may prove to be very useful, safe, easy to perform, and cost effective as a second-line therapy for resistant PCOD in cases where medical inductions fail to achieve ovulation.

Effects of Ringer's lactate, Interceed(TC7) and Gore-Tex Surgical Membrane on postsurgical adhesion formation

Pagidas K et al., 1992 · Fertil Steril ·

To evaluate the effects of Ringer's lactate instillation, Interceed(TC7) (Johnson and Johnson Medical, Inc., New Brunswick NJ), and Gore-Tex Surgical Membrane (W. L. Gore and Associates, Inc., Flagstaff, AZ) in a rat uterine horn model. Rats were in a conventional laboratory setting. Sprague-Dawley white rats, weighing 225 to 250 g. The left uterine horn was subjected to a standardized lesion by serosal denudation and devascularization. The rats were randomly assigned into control group, Interceed(TC7) group, Gore-Tex group, and Ringer's lactate group. Degree of adhesions was evaluated 2 weeks after the initial surgery. Adhesion score after Ringer's lactate instillation was significantly lower than those of control, Interceed(TC7), and Gore-Tex groups. Gore-Tex was associated with less adhesion formation than control. No difference was found in the adhesion formation between the Interceed(TC7) group and the control group. Confirming our previous observations, Ringer's lactate instillation is effective in decreasing adhesion formation. Gore-Tex reduces adhesion formation, but its efficacy is inferior to those of Ringer's lactate. Contrary to previous reports, Interceed(TC7) is ineffective in our animal model.

Murine peritoneal injury and de novo adhesion formation caused by oxidized-regenerated cellulose (Interceed [TC7]) but not expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane)

Haney AF et al., 1992 · Fertil Steril ·

To evaluate the impact of the materials contained in the available adhesion prevention barriers on the peritoneum. STUDY DESIGN, SETTING, A murine paradigm was used, placing oxidized-regenerated cellulose (Interceed [TC7]) and expanded polytetrafluoroethylene (PTFE; Gore-Tex Surgical Membrane) in the peritoneal cavity for intervals up to 14 days. MAIN The appearance of the peritoneum on scanning and transmission electron microscopy and the presence of de novo adhesions were the end-points used. Oxidized-regenerated cellulose caused localized sloughing of the mesothelial cell layer and leukocyte infiltration of the deeper tissue leading to the formation of adhesions to the bowel and liver in 58% of the animals. The surface of the oxidized-regenerated cellulose-injured peritoneum healed in 5 to 7 days. Neither peritoneal injury nor adhesions were noted in sham-operated animals or animals with PTFE. Oxidized-regenerated cellulose but not PTFE has a localized injurious effect on the peritoneum of the mouse, resulting in de novo adhesions. The impact of the barrier material itself on normal peritoneum may be an important consideration in designing surgical barriers for the prevention of postoperative adhesions.

Evaluation of adhesion formation after laparoscopic treatment of polycystic ovarian disease

Kişnişçi H et al., 1991 · Fertil Steril ·

The incidence and fertility effects of postoperative adhesion formation after laparoscopic ovarian electrocautery or laser photocoagulation of polycystic ovaries has not been adequately analyzed. Short-interval second-look laparoscopy appears to be a useful method for addressing this issue. Employing short-interval second-look laparoscopy 3 to 4 weeks after the initial laparoscopic intervention, we were able to demonstrate adhesions in 6 of 7 patients (85%) treated with ovarian electrocautery and 8 of 10 patients (80%) submitted to laser therapy. The adhesions were amenable to laparoscopic lysis in 12 of 14 patients (85%). The subsequent conception rates within 6 months of second-look laparoscopy that were 57% and 40% in the electrocautery and the Nd:YAG laser groups, respectively, may in part be attributed to the restoration of normal pelvic anatomy during this procedure.

Histology of proximal tubal obstruction in cases of unsuccessful tubal canalization

Letterie GS et al., 1991 · Fertil Steril ·

To determine possible etiologies of unsuccessful fluoroscopically guided tubal canalization, we studied the histology of tubal segments in cases of failed canalization for proximal tubal obstruction. Factors contributing to cases of unsuccessful fluoroscopically guided tubal canalization remain unclear. Prospective. Reproductive Endocrinology Clinic. Twenty-seven cornual and/or isthmic tubal segments from 15 patients who underwent proximal tubal surgery after fluoroscopically guided tubal canalization were studied. Specimens were prepared with hemotoxylin-eosin and Masson trichrome stains. Histologic examination of excised cornual and isthmic tubal segments revealed abnormalities in 93% of specimens. Obliterative fibrosis (61%), chronic salpingitis (57%), and salpingitis isthmica nodosa (42%) were the most commonly found histologic tubal abnormalities. One case of complete tubal occlusion and tubal schistosomiasis was also detected. These data suggest that cases of failed fluoroscopically guided tubal canalization may be secondary to severe intrinsic tubal disease and tubal occlusion and not to the technique. Fluoroscopically guided tubal canalization may provide a means of differentiating a functional obstruction amenable to conservative management from true occlusion requiring management by microsurgical techniques or in vitro fertilization.

Adhesion formation after ovarian electrocauterization on patients with polycystic ovarian syndrome

Dabirashrafi H et al., 1991 · Fertil Steril ·

The rate of adhesion formation after ovarian electrocauterization has been described in two selective and unselective groups of patients with PCOS. The rate of this complication in the selective group was 0 from 16 ovaries and in the unselective group (5/25). However, the rate of major adnexal adhesion in the unselective group was 1 from 25 ovaries.

Myomectomy as a reproductive procedure

Smith DC et al., 1990 · Am J Obstet Gynecol ·

This series of 64 myomectomies describes the indications, technique, and efficacy of the procedure; the majority of operations were performed on large multinodular uteri. Indications included enlarging pelvic mass, menorrhagia, anemia, and pregnancy wastage in women who wished to preserve reproductive capability. Although infertility was not the primary indication in any case, 32 patients were nulligravid. Only 10 patients were parous and 14 had a history of spontaneous abortion or pregnancy wastage. The average age of the patients was 35.8 years (range, 27 to 47 years). There were no major complications and no patients received blood transfusions. Follow-up revealed three patients with recurrent tumors necessitating repeat procedures. Successful pregnancies have occurred in 40% of those attempting pregnancy. It is concluded that successful myomectomy can be performed in most patients regardless of uterine size, thereby preserving reproductive potential.

Diagnosis and treatment of cornual obstruction using a flexible tip guidewire

Deaton JL et al., 1990 · Fertil Steril ·

Proximal tubal obstruction, either unilateral or bilateral, is a frequent finding on hysterosalpingogram (HSG). Approximately two-thirds of the fallopian tubes resected for proximal tubal obstruction reveal an absence of luminal occlusion. The distinction between true pathologic occlusion and either spasm or plugging is crucial in determining therapy. We combined hysteroscopic cannulation of the proximal fallopian tube with laparoscopy in 11 patients with proximal tubal obstruction diagnosed by HSG and confirmed at laparoscopy. Hysteroscopic cannulation was able to be performed in 72% of the fallopian tubes attempted, and there was a postcannulation patency rate by HSG of 73%. Six of the 11 patients became pregnant after tubal cannulation and adjunctive distal tubal surgery. Hysteroscopic cannulation of the fallopian tube is a safe diagnostic procedure that can be used to identify those patients with true proximal occlusion, and may also serve as a therapeutic procedure in some of these patients.

Safety of intraperitoneal 32% dextran 70 as an antiadhesion adjuvant

Ricaurte E et al., 1989 · J Reprod Med ·

The records of 139 consecutive patients who underwent major gynecologic abdominal surgery in which 32% dextran 70 was used as an antiadhesion adjuvant were carefully reviewed for the presence or absence of dextran-related complications. Eleven patients (8.0%) were thought to have dextran-related complications, including postoperative ileus (2.9%), pleural effusion (2.2%), allergic reactions (1.4%), wound infection (1.4%) and labial swelling (0.7%). The mean amount of dextran used was 183 mL. The study indicated that dextran can be used in moderate amounts when instilled intraperitoneally and has an acceptably low rate of complications. Since dextran is used often in spite of scanty evidence of its effectiveness as an antiadhesion adjuvant, understanding its safety and potential complications is especially important.

Prevention of postsurgical adhesions by INTERCEED(TC7), an absorbable adhesion barrier: a prospective randomized multicenter clinical study. INTERCEED(TC7) Adhesion Barrier Study Group

Adhesion Barrier Study Group, 1989 · Fertil Steril ·

INTERCEED(TC7) (Johnson & Johnson Patient Care Inc., New Brunswick, NJ) is an absorbable fabric specially designed to reduce postsurgical adhesions. The authors report on a prospective, randomized, multicenter, clinical trial that evaluated the efficacy of Interceed in reducing adhesions in humans. Infertility patients (n = 74) with bilateral pelvic sidewall adhesions were studied at treatment laparotomy and "second-look" laparoscopy to determine Interceed's effectiveness. After removal of adhesions at laparotomy, the deperitonealized area of one pelvic sidewall was covered with Interceed. The contralateral untreated sidewall served as the control. Pelvic sidewalls covered with Interceed had a 90% improvement over control sidewalls in preventing adhesion formation. Additionally, Interceed treatment was associated with a 57% reduction of the extent of adhesion formation over that obtained by microsurgical techniques alone. Interceed also provided a significant benefit in reducing the severity of those adhesions that did form, and significantly reduced the number of adhesions between the ovary and pelvic sidewall. In conclusion, Interceed significantly reduced the incidence, extent, and severity of postsurgical pelvic adhesions.

Assessment of carboxymethylcellulose and 32% dextran 70 for prevention of adhesions in a rabbit uterine horn model

Diamond MP et al., 1988 · Int J Fertil ·

The ability of solutions of carboxymethylcellulose (CMC) and 32% dextran 70 to reduce postoperative adhesion formation was examined using a rabbit uterine-horn scrape model. Utilization of 50 mL of 32% dextran 70 did not reduce adhesion formation compared with control rabbits. However, intraperitoneal instillation of CMC significantly reduced postoperative adhesion formation. An inverse correlation was established between either the concentration of CMC employed (1%, 2%, and 3%) or the volume of 2% CMC employed (20, 30, 40, and 50 mL) and the extent of adhesion formation. It is concluded that in this animal model CMC, but not 32% dextran 70, was able to retard postoperative adhesion formation.

Prevention of pelvic adhesion formation by different modalities of treatment

Fayez JA et al., 1987 · Am J Obstet Gynecol ·

This prospective study was designed to investigate the effect of glucocorticoids, promethazine (Phenergan), hyskon, heparin, and Ringer's lactated solution in the prevention of pelvic adhesion formation after pelvic surgery. The patients were divided into two groups: The first consisted of 396 patients who had laparotomy for different types of pelvic surgery, and the second group consisted of 546 patients who had operative laparoscopy for different types of pelvic disease. Patients in these two major groups were divided prospectively into different subgroups with different modalities of adjuvant therapy to prevent postoperative pelvic adhesions. A second-look laparoscopy was performed for some of the patients who failed to conceive in each of these subgroups. Pregnancy rate and adhesion formation were compared between these subgroups with no statistical difference noted. It is concluded that glucocorticoids, promethazine, heparin, and hyskon have no therapeutic advantage over Ringer's lactated solution in the prevention of postoperative pelvic adhesion formation.

Isthmic ectopic pregnancy and salpingitis isthmica nodosa

Homm RJ et al., 1987 · Fertil Steril ·

Two hundred eighty-five charts were reviewed from patients who underwent surgery for ectopic pregnancy. Excluded were patients with previous tubal reparative surgery, linear salpingotomy, or failed sterilization. The incidence of isthmic ectopic pregnancy in the remaining 255 cases was 15.3%. The association of salpingitis isthmica nodosa (SIN) and isthmic ectopic pregnancy was determined by review of resected tubal segments. SIN was noted in 17 of 37 cases (45.9%) of isthmic ectopic pregnancy. SIN places the patient at risk for recurrent ectopic pregnancy or infertility. Recommended conservative management of isthmic ectopic pregnancy is segmental resection with postoperative emphasis on documentation of SIN when present. Postoperative hysterosalpingography is recommended with an abnormal contralateral tube or when SIN is noted in the resected tubal segment. Management options after an isthmic ectopic pregnancy when future fertility is desired are presented.

Adhesion prevention in the rabbit with sodium carboxymethylcellulose solutions

Fredericks CM et al., 1986 · Am J Obstet Gynecol ·

With the use of a rabbit surgical model, the ability of 1%, 2%, and 3% solutions of sodium carboxymethylcellulose to reduce postoperative uterine adhesions was determined. At all concentrations sodium carboxymethylcellulose was more effective than either 32% dextran 70 or heparinized lactated Ringer's solution. Neither the dextran nor Ringer's solution had a significant (p less than or equal to 0.05) effect. The beneficial effects of sodium carboxymethylcellulose were closely dose-dependent (correlation coefficient 0.97). Sodium carboxymethylcellulose is highly effective in reducing postoperative adhesions in laboratory animals, and additional studies are warranted to further define its efficacy and safety.

Failure of intraperitoneal adjuncts to improve the outcome of pelvic operations in young women

Jansen RP, 1985 · Am J Obstet Gynecol ·

An examination was made of the possibility that 100 to 200 ml of intraperitoneal 32% dextran 70 and/or 0.5% hydrocortisone sodium succinate (randomized independently with similar volumes of Ringer's lactate solution) might help to lessen the postoperative formation of adhesions among patients undergoing surgical procedures for peritubal adhesions (n = 76), endometriosis (n = 27), or midtubal occlusion (n = 61). Patients in the first two groups who were given intraperitoneal corticosteroids were also given systemic steroids. Nonparametric comparison of median adhesion scores at operation and at subsequent laparoscopy showed that there was a poorer outcome with dextran than when dextran was not used in every subgroup except one (repeat salpingolysis after previous operation for adhesions), including first operations for adnexal adhesions (Mann-Whitney U = 200, m = 23, n = 26; p less than 0.05). The probability was small (p beta less than 0.002) that an important beneficial effect of dextran was overlooked. Systemic corticosteroids were associated with a consistent trend toward improved outcome, especially in patients who initially had few or no adhesions, such as those operated on for endometriosis (U = 2, m = 7, n = 4; p less than 0.025), but among patients with tubal resections and anastomoses with adnexal adhesions the use of intraperitoneal hydrocortisone alone was associated with a worse outcome (U = 15, m = 12, n = 8; p less than 0.02). Life-table analysis of the accumulating probability of pregnancy showed that no significant difference resulted from adjunct use in any group. The conclusion is that no empiric basis supports the use of intraperitoneal 32% dextran 70 or 0.5% hydrocortisone in the attempt to prevent peritoneal adhesions, but further investigations on the systemic administration of corticosteroids to decrease the formation of adhesions would be useful.

Effect of intraperitoneal instillation of 32% dextran 70 on postoperative adhesion formation after tubal surgery

Larsson B et al., 1985 · Acta Obstet Gynecol Scand ·

The intraperitoneal instillation of 32% dextran 70 (HyskonR, Pharmacia AB, Sweden) has previously been reported to prevent the formation of postoperative adhesions. Against this background, the present study was undertaken to evaluate the efficacy of HyskonR in counteracting peritoneal adhesions following tubal microsurgery. 105 infertile women were operated upon in a prospective, randomized, controlled, double-blind, multicenter study. The intra-abdominal adhesions present from the beginning were classified by means of a standardized scoring scale and the extent of adhesions was again evaluated at follow-up laparoscopy 4-10 weeks later. A reduction in the extent of the intra-abdominal adhesions (statistically highly significant) was revealed in both the Hyskon group and the saline control group. The extent of adhesions in the Hyskon group was not lesser than in the saline group, however. The pregnancy rates in the two groups were also similar.

Adhesion prevention by solutions of sodium carboxymethylcellulose in the rat. I

Elkins TE et al., 1984 · Fertil Steril ·

Solutions of sodium carboxymethylcellulose (SCMC) were studied in rats to determine their longevity within the peritoneal cavity and their potential for prevention of postoperative intraperitoneal adhesions. In 18 rats, test solutions of SCMC and 10% dextran 40 were instilled at laparotomy. At 48 hours copious amounts of SCMC remained, whereas no 10% dextran 40 could be detected. In addition, standardized surgical injury was produced on the ceca of 100 rats at laparotomy. All control animals had significant adhesions at 2 weeks. Eighty-two percent of the 10% dextran 40 group had significant adhesions, while only 16% of the 0.9 wt% SCMC and 17% of the 1.0 wt% SCMC groups had significant adhesions. Solutions of SCMC were significantly more effective than 10% dextran 40 in the prevention of adhesions (P less than 0.001). Properties of SCMC and a possible mechanism for its striking effectiveness in adhesion prevention in this study are discussed.

Preventing postoperative pelvic adhesions with intraperitoneal treatment

DeCherney AH, 1984 · J Reprod Med ·

Postoperative pelvic adhesions represent a major challenge to the surgeon operating to correct or prevent infertility. Many approaches have been tried, but intraperitoneal treatment seems to be the most efficacious. Some major landmarks led to the development of the intraperitoneal substances currently used to prevent postoperative pelvic adhesions. On comparing the data on both animals and humans we see that high-molecular-weight dextran seems to be superior to other substances. Much work needs to be done to enhance this adjunctive therapy since excellent surgical technique alone seems insufficient. The future emphasis will probably be on these medications in conjunction with precise surgical techniques and adjunctive intraperitoneal therapy.

High-molecular weight dextran in human infertility surgery

Rosenberg SM et al., 1984 · Am J Obstet Gynecol ·

The use of intraperitoneal 32% high-molecular weight dextran 70 (Hyskon, Pharmacia Inc.) has been reported to reduce the incidence of surgical adhesions in several species. The present study was undertaken to determine the effect of 32% dextran 70 in human females who underwent major abdominal infertility operations. Adhesions were quantitated by means of standardized objective criteria in 44 women in a prospective, randomized, double-blind study, and reevaluated at second-look laparoscopy approximately 6 weeks later. The mean change in the adhesion score for all patients in the 32% dextran 70 group (n = 23) was -2.57 units (i.e., clinically "improved") versus +2.41 units (i.e., clinically "worsened") in the control group (n = 21), p = 0.016. For the subgroup of patients who underwent lysis of adhesions, the 32% dextran 70 group (n = 17) improved significantly, whereas the control group (n = 12) tended not to improve with careful technique alone (-4.2 units versus +0.3 unit, p less than 0.05). These data indicate that 32% dextran 70 not only significantly reduces the formation of adhesions overall in human infertility operations, but also is highly effective in reducing the reformation of adhesions after lysis.

Reduction of postoperative pelvic adhesions with intraperitoneal 32% dextran 70: a prospective, randomized clinical trial

No Authors Listed, 1983 · Fertil Steril ·

Infertile women of reproductive age requiring an operation for distal tubal disease, endometriosis, or pelvic adhesions were recruited from nine study centers. Prior to closing the peritoneal cavity, 250 ml of 32% dextran 70 (n = 55) or saline (n = 47) was instilled into the dependent portion of the pelvis; 8 to 12 weeks later, laparoscopy was performed on those patients not pregnant. Patients with severe adnexal adhesions at the initial laparotomy had a greater reduction in adhesions if they received 32% dextran 70. Further, patients with a marked reduction in adhesion formation following the initial laparotomy were found to occur more frequently in the 32% dextran 70-treated group (26 of 51 for 32% dextran 70 versus 12 of 40 for saline; P less than 0.05). During second-look laparoscopy, adhesions were found to occur more frequently in control patients than in 32% dextran 70-treated patients at the following anatomic sites: ovary (P less than 0.05); cul-de-sac (P = 0.017); pelvic side wall (P less than 0.001). Thus, in a prospective, randomized, blinded clinical trial, the intraperitoneal high-molecular-weight dextran was found to reduce postoperative adhesion formation effectively.

Fertility following bilateral ovarian wedge resection: a critical analysis of 90 consecutive cases of the polycystic ovary syndrome

Adashi EY et al., 1981 · Fertil Steril ·

Fertility following bilateral ovarian wedge resection (BOWR) was evaluated in a retrospective cohort study of 90 consecutive cases of the polycystic ovary syndrome. Post-BOWR follow-up was available for varying time spans of up to 10 years. BOWR resulted in the resumption of menstrual cyclicity in 91.1% (82/90) of the cases. However, within this ovulatory group, 26 patients were characterized by oligo-ovulation and a significantly reduced conception rate (29.2%), as compared with that of 56 normo-ovulatory counterparts (60.3%). Although the crude overall conception rate for this series was 47.8%, the overall cumulative probability of conception at the end of follow-up as determined by life table analysis was 73%. The likelihood of conception at any given point in time was estimated by a monthly fecundability rate of 1.34%. Our findings also indicate that the probability of post-BOWR conception was unaffected by age, race, ward status, or duration of infertility. In contrast, persistent post-BOWR oligo- or anovulation and the presence of concurrent tuboperitoneal disease were reaffirmed as the most important determinants of the likelihood of post-BOWR conception. A minimum incidence of 7.8% was documented for acquired post-BOWR pelvic disease.

Prevention of postoperative tubal adhesions. Comparative study of commonly used agents

Hodger GD et al., 1980 · Am J Obstet Gynecol ·

Tubal abrasions were surgically induced in 25 rhesus monkeys following demonstration of tubal patency. Five monkeys received dexamethasone, promethazine, and ampicillin perioperatively, five received intraperitoneal 10% dextran 40, five received intraperitoneal 32% dextran 70, and 10 received no additional therapy. Fimbrial biopsies were obtained from two additional monkeys treated with 32% dextran 70 before and postoperatively on days 2, 5, and 7. Only those treated with 32% dextran 70 retained tubal patency and avoided development of adhesions, involving fimbria, omentum, ovary, uterus, and bladder. Histologic examination of fimbrial biopsies demonstrated sufficient epithelial repair to have occurred during the 5 days 32% dextran 70 remained in the pelvin cavity to prevent adhesion formation.

Role of dextran 70 in microtubal surgery

Utian WH et al., 1979 · Fertil Steril ·

Pelvic adhesion formation represents a major problem following fallopian tube surgery for infertility. Intraperitoneal dextran may prevent pelvic adhesions. Extensive personal clinical experience (W. H. U.) with intraperitoneal dextran organ-flotation on completion of tubal and ovarian surgery has appeared to limit adhesions. A specific study was designed to test the validity of this theory. Four randomized groups of rabbits were subjected to bilateral tubocornual division and microsurgical reanastomosis with total hemostasis and pelvic lavage. Routine peritoneal closure was performed on one group, but followed instillation of 30 to 50 ml of normal saline into the peritoneal cavities of the second group, and 30 to 50 ml of 6% dextran 70 into those of the third. Study of fourth group, which received 32% dextran 70 in the peritoneal cavity, was discontinued because of complications. A second laparotomy was performed 4 weeks later for precise assessment and photography of adhesion formation. Each animal was mated 4 weeks after the second operation in order to determine fertility rates. Reduced adhesion formation and increased fertility rates following the instillation of dextran are reported. A role for dextran 70 in infertility surgery is recommended.

Salpingostomy by microsurgery

Gomel V, 1978 · Fertil Steril ·

Salpingostomy for hydrosalpinx was carried out using a microsurgical technique. The postoperative patency rate was over 90%. Among the 41 patients followed for more than 1 year, 29% have had one or more intrauterine pregnancies and 27% have had live births. The ectopic gestation rate was 12%. All of the tubal gestations occurred in the 1st postoperative year whereas 60% of the intrauterine pregnancies occurred after the 1st year, suggesting a degree of restoration in the mucosa and the musculature of the oviduct with the re-establishment of patency and the passage of time.

Infertility following wedge resection of the ovaries

Toaff R et al., 1976 · Am J Obstet Gynecol ·

Seven cases of polycystic ovarian disease were investigated by laparoscopy and endocrinologic tests after failure of ovarian resection to restore fertility. One case of bilateral and two cases of unilateral ovarian atrophy were recorded. In all seven patients the common features were extensive perivarian and peritubal adhesions. Four of the six patients amenable to cure were submitted to reconstructive surgery; three of them conceived and had normal deliveries. The present observations support the plea to relegate the surgical approach to a minor position in patients with Stein-Leventhal syndrome and stress the importance of meticulous surgical technique in the performance of ovarian surgery. Laparoscopic investigation is mandatory in all cases of unsuccessful ovarian resection.

The prevention of postoperative pelvic adhesions following conservative operative treatment for human infertility. A final 3-year follow-up report

Horne HW Jr et al., 1973 · Int J Fertil ·

A combination of Decadreon (dexamethasone) and Phenergan (promethazine) was tested in this collaborative study of 240 infertility patients as a means of preventing postoperative adhesion formation after simple pelvic surgery. 24 patients were lost to follow-up. The overall pregnancy rate among the 240 patients was 51.7% (124): 49% with primary infertility and 58% with secondary infertility conceived after surgery. 90 full-term deliveries were recorded, 27 spontaneous abortions occurred, and 7 ectopic gestations were conceived. In all, 31 cases were reinspected for various reasons after the drug treatment postsurgery; 42% showed no adhesions, 23% showed minimal adhesions, and 35% had significant adhesions. Complications coincident with use of the combined medication were seen in 2.2% (11 of 240) patients. Though this study lacked controls, the authors feel thta the use of corticosteroids postoperatively after pelvic intervention may control the numbers of adhesions which form postoperatively.

An instrument for transcervical treatment of the oviducts and uterine cornua

Corfman PA et al., 1966 · Obstet Gynecol ·

A new instrument has been designed to treat the primate uterine cornua and oviducts. 2 versions of the instrument are described. Both versions are 12 cm long. One is 3 mm in diameter, and the other is 3.5 mm. Tips may be manufactured to hold different volumes of fluid. The Teflon piston which is moved inside the tip, forces the fluid out through a small hole at the end. The piston is actuated from the proximal (operator's) end of the strument. Silicon rubber tubing may be filled with air or fluid from the stopcock at the operator's end through a fine tube which runs inside the instrument. In an attempt to determine if the instrument will locate fluids reliably and accurately, a vital stain, cresyl violet, has been used to inject normal sized uteruses in 6 patients prior to operation for various conditions. In 3 patients, both cornua were successfully stained with dye. In 2 patients, the cornu on only 1 side was seen to be stained, and in 1 patient, no stained areas were identified. Suggested applications of the instrument include: 1) investigation of oviduct physiology; 2) temporary sterilization; and 3) permanent sterilization.

Ovarian resection for the relief of sterility

Meaker SR, 1950 · Fertil Steril ·

More than twenty-five years ago Edward Reynolds gave an excellent description of the polycystic ovary, and expressed the opinion that ovarian surgery was the most important single feature in the treatment of sterility of the female. This view was not accepted by later workers in the field. Indeed, the tendency has been to consider retention cysts as items of small importance, unlikely to cause symptoms and rarely calling for treatment on their own account. It remained for Stein15- 18 and his followers to define a type of case where the presence of multiple cysts evidently interferes both with ovulation and with endocrine activity, and to show that surgery frequently succeeds in restoring normal function. I propose to discuss certain aspects of this clinical problem, and to report my own series of 65 operated cases. The fundamental cause of retention cysts is probably, as Zondek believes, a phase of hypergonadotropism. Under normal conditions large numbers of primordial follicles start to mature but never complete the process. At some point along the way the ova die, whereupon the follicles regress and ultimately become insignificant corpora fibrosa. Under the influence of excessive pituitary stimulation, however, such follicles may continue to secrete liquor and to grow after the disappearance of their ova. Some of them eliminate themselves by delayed resorption and atrophy or, less often, by rupturing through the tunica albuginea. Others remain as permanent cystic structures. These retention cysts are pathologic, whereas atretic follicles in various stages of regression represent nothing more than phases of the normal ovulatory cycle.

FACTS Elective Case: A Life Saving Fertility Surgery

Whittaker NM,

Male Reproductive Surgery

UCSF Center for Reproductive Health, · UCSF Center for Reproductive Health

Overview of male reproductive surgery from UCSF's Center for Reproductive Health. Anatomical (surgical) male-factor problems can often be corrected with surgery, while some require medical therapy or assisted reproduction; effects on semen appear ~3 months after treatment (one spermatogenesis cycle). Covers varicocele (found in 42% of infertile men; semen improvement in ~67% and ~40% pregnancy after repair), vasectomy reversal (vasovasostomy with 85-99% return of sperm and 60-65% pregnancy with a healthy partner), ejaculatory duct obstruction (resection improves semen in ~70%, 20-30% pregnancy), and sperm-retrieval techniques (MESA, PESA, testicular extraction, testis mapping) used with IVF-ICSI when reconstruction is not possible.

Combined hysteroscopic and laparoscopic management of an isthmocele: about a case report

Slaoui A et al., 2025 · International Journal of Surgery Case Reports · Open Access

This case underscores the effectiveness of a combined laparoscopic and hysteroscopic approach in managing isthmocele, achieving symptom resolution and uterine integrity restoration. Individualized management and long-term follow-up are essential for optimizing outcomes.

Revitalizing reproductive health: innovations and future frontiers in restorative medicine

Bulletti FM et al., 2025 · Clin Med�Insights�Reprod�Health · Open Access

Infertility affects around 17.5% of reproductive-aged individuals worldwide, posing significant personal and public health challenges. Although Medically Assisted Reproduction and Assisted Reproductive Technology (ART; e.g., in vitro fertilization) have advanced outcomes, many couples fail to conceive due to unaddressed pelvic, uterine, or systemic factors. We aim to (1) define the current usage of Restorative Reproduction Medicine (RRM) in clinical practice, (2) compare RRM outcomes with conventional ART, and (3) propose an integrated model of RRM plus ART for optimal fertility care. A systematic review following PRISMA guidelines was conducted (INPLASY registration no. INPLASY2024110069). Data sources and We searched PubMed, Scopus, and Web of Science (January 1995–October 2024), combining terms such as “restorative reproductive medicine,” “intrauterine adhesions,” “myomas,” “polyps,” “hydrosalpinx,” “endometritis,” “BMI,” “thyroid dysfunction,” “microbiome,” and “assisted reproductive technology.” Inclusion criteria: studies on uterine/systemic factors affecting infertility, focusing on surgical/pharmacological RRM interventions and ART limitations. Exclusion criteria: male-only infertility, case reports, narrative reviews, non-English publications. Quality assessment employed the Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool. We also briefly noted potential publication bias due to language and study-type restrictions. From >25,000 initial titles, 3 sequential screenings yielded 145 key articles addressing uterine (septum, myomas, polyps, adhesions) and systemic (body mass index (BMI) extremes, thyroid dysfunction, microbiome imbalance) factors. Surgical corrections (e.g., hysteroscopic removal of polyps/myomas, salpingectomy for hydrosalpinx) significantly improved natural conception and ART success (⩾20%–40% increase in clinical pregnancy). Chronic endometritis treatment, endometrial microbiome modulation, and BMI/thyroid optimization further improved pregnancy rates by 15%–20%. Comparisons of RRM versus ART alone indicated that RRM often lowers overall cost and may reduce miscarriage, while ART offers immediate embryo transfer. Combining RRM to correct pathologies prior to ART can boost implantation and live birth rates (⩾40%–70% improvement in some studies). Restorative Reproductive Medicine comprehensively addresses pelvic and systemic abnormalities, thereby enhancing fertility outcomes and complementing ART. A proposed integrated model—RRM diagnostics/interventions followed by ART if needed—maximizes success, reduces time/cost, and emphasizes holistic reproductive health. Further multicenter trials are warranted to standardize protocols and fully realize RRM’s potential in modern fertility care.

Vasectomy

Mayo Clinic, 2025 · Mayo Clinic

Mayo Clinic patient overview of vasectomy, a permanent male contraceptive procedure that cuts and seals the vas deferens. Covers indications, the no-scalpel technique, risks, recovery, and semen testing. Notes vasectomy reversal and IVF are possible after vasectomy but are harder, costly, and not guaranteed, so vasectomy should be considered permanent. By Mayo Clinic Staff, updated March 7, 2025.

The Long-term Rate of Repeat Surgery After Optimal Excision Surgery of Endometriosis at a Single Tertiary Referral Center

Yeung P et al., 2025 · Acta Scientific Women's Health ·

The primary purpose of this prospective cohort study was to determine if treating endometriosis with optimal excision surgery leads to lower rates of repeat surgery as compared to historical rates of repeat surgery by ablation. A secondary outcome was to examine whether the use of hormonal suppression differed before surgery, depending on the stage of endometriosis found at surgery. Optimal excision was defined as completely excising all areas of abnormal peritoneum, wherever found in the pelvis, having looked systematically with near contact laparoscopy. All surgeries were performed by a single surgeon specializing in optimal excision at a tertiary referral center. The rate of repeat surgery after optimal excision surgery for endometriosis was remarkably low (2.5%, 15/620) as compared to historical rates of repeat surgery by ablation. Additionally, the lack of significant evidence between hormonal suppression use and progression of stage of endometriosis provides implicit evidence that hormonal suppression does not prevent progression of the disease. Further controlled studies are needed to verify these findings.

Relationship between chronic endometritis and fallopian tube obstruction and its influence on pregnancy outcome after fallopian tubal recanalization

Sun Y et al., 2024 · Ther Adv Reprod Health · Open Access

Chronic endometritis (CE), frequently asymptomatic, is associated with female infertility. Fallopian tube obstruction (FTO) is also one of the factors contributing to female infertility. More than 90% of cases of proximal FTO can be successfully treated after fallopian tubal recanalization (FTR) and the spontaneous pregnancy rate of treated women after FTR is only about 30%. Potential factors affecting the success rate of FTR remain unclear. We speculate that CE may be one of the reasons affecting the recanalization of the fallopian tubes. To identify the correlation between CE and FTO, as well as the influence of CE on pregnancy outcomes following FTR. Retrospective observational study. We retrospectively analyzed 498 women of childbearing age who underwent laparoscopy and hysteroscopy surgery for infertility. Endometrial samples were collected during surgery for CD138 immunohistochemistry staining for the diagnosis of CE. Based on the results of the tubal patency test, they were divided into two groups: the fallopian tubal patency group and the proximal FTO group. The prevalence of CE was compared between these two groups. All women with FTO underwent FTR during the operation until successful treatment was achieved. Pregnancy outcomes were assessed after a 12-month follow-up period following the procedures. Logistic regression was used to analyze factors that might affect pregnancy after FTR. The prevalence of CE in women with tubal obstruction was 30.5%, which was significantly higher than that in the fallopian tubal patency group (10.75%), p < 0.001. After FTR, the prevalence of CE in non-pregnant women was 40.18%, which was higher than that in pregnant women (40.18% vs 13.11%), and the difference was significant (p < 0.001). Multiple regression analysis showed that CE was a significant risk factor for FTO (OR: 2.54, 95% CI: 1.368-4.717, p < 0.05). In addition, CE was identified as a risk factor for infertility after FTR (OR: 4.730, 95% CI: 2.012-11.122). The presence of CE seems to decrease the likelihood of achieving spontaneous pregnancy following FTR. This observation underscores the clinical importance of early detection and treatment of CE, emphasizing the necessity for immediate intervention to prevent potential fertility complications.

Current surgical treatment of uterine isthmocele: an update of existing literature

Stavridis K et al., 2024 · Arch Gynecol Obstet ·

The prevalence of uterine isthmocele, also known as a uterine niche, has risen in parallel with increasing cesarean section (CS) rates, affecting approximately 60% of women depending on their history of cesarean deliveries. This condition, now categorized as cesarean scar disorder (CSD) by the "Delphi consensus," is characterized by one primary or two secondary symptoms. Diagnosis can be made through transvaginal ultrasound, sonohysterography, hysteroscopy, or magnetic resonance imaging (MRI). Management of isthmocele may involve pharmacological or surgical interventions. This review aims to provide a thorough analysis of the surgical management options, focusing on postoperative symptom relief, intraoperative and postoperative complications, length of hospital stay, and impact on secondary infertility. PubMed was comprehensively searched for observational studies from inception to 07.08.2024. Surgical treatments include hysteroscopic resection, laparoscopic procedures, and vaginal approaches, all of which offer comparable symptom relief. However, the vaginal approach is associated with a longer hospital stay. The robotic-assisted approach shows promising results but lacks extensive data. Among surgical options, hysteroscopic treatment has the fewest complications but is generally avoided when residual myometrial thickness (RMT) is less than 3 mm. While many CSDs remain asymptomatic, and some women with uterine isthmocele may not wish to conceive, symptomatic patients or those desiring to conceive may benefit from surgical intervention. The choice of procedure should be based on individual patient characteristics, particularly RMT, to define the most appropriate surgical approach.

Is Vaginal Repair a Good Option for Severe Cesarean Scar Defect? Comparison of Women With or Without Residual Myometrium

Bardet L et al., 2024 · J Minim Invasive Gynecol ·

To compare outcomes of vaginal surgery in women with moderate or severe symptomatic cesarean scar defect (with or without residual myometrium). Retrospective cohort study. Gynecology department of a teaching hospital. Fifty-three women, between January 2014 and December 2019, underwent vaginal surgery for symptomatic cesarean scar defect: 20 women with moderate defect (with residual myometrium) and 33 with severe defect (without residual myometrium). Vaginal surgical approach to repair cesarean scar defect. MAIN surgery by comparing the myometrial residual thickness before and after surgery. The secondary objectives were evaluation of vaginal surgery efficacy on symptoms resolution, per and postoperative courses, and subsequent fertility. Failure rate was evaluated as the need for a second surgery. After vaginal surgery, the residual myometrium significantly increased from 2.4 mm ± 0.9 mm to 6.6 mm ± 2.4 mm (p <.01) in the moderate group and from 0 mm to 4.4 mm ± 2.2 mm (p <.01) in the severe group. The prevalence of abnormal uterine bleeding was significantly reduced after surgery in both groups (p <.01). Pelvic pain was significantly reduced only in the moderate group (p <.01). The rate of complications (5% vs 9.1%) and second surgery (15% vs 24.2%) were not significantly different between moderate and severe groups, respectively. The median time to conceive (7 months vs 12 months); pregnancy rates (84.6% vs 68.2%); and live birth rates (76.9% vs 50%) were not statistically significant in the moderate and severe groups respectively, with 90% of pregnancies occurring naturally. Women delivered by cesarean section at 38 weeks of gestation in both groups, and no uterine rupture was reported. Despite the absence of residual myometrium, vaginal repair of severe cesarean scar defect was effective in increasing myometrial thickness, in relieving bleeding symptoms, and in allowing to achieve pregnancy.

Comparison of laparoscopic and hysteroscopic surgical treatments for isthmocele: A prospective cohort

Hosseini R et al., 2024 · Turkish journal of obstetrics and gynecology

To evaluate the clinical outcomes of laparoscopic and hysteroscopic surgical approaches for treating symptomatic isthmocele and identify their associated factors. Forty-six patients with symptomatic isthmocele diagnosed using transvaginal saline infusion sonohysterography were enrolled in this prospective cohort study. Patients underwent either laparoscopic or hysteroscopic isthmoplasty based on their residual myometrial thicknesses and fertility desires and were subsequently followed by clinical and ultrasonographic examinations. Twenty-two patients underwent laparoscopy and 24 underwent hysteroscopic surgery. At baseline, there was no significant difference in the mean age and years since the last cesarean section between the two groups. However, the hysteroscopy group had a higher mean parity and previous cesarean sections (p=0.00, 0.03). The most common symptoms were abnormal uterine bleeding, infertility, and dysmenorrhea. The mean baseline residual myometrial thickness was significantly higher in the laparoscopy group (p=0.00), and only laparoscopic surgery led to a significant increase in residual myometrial thickness in patients (p=0.00). Both procedures significantly reduced abnormal uterine bleeding (p=0.00), but only laparoscopy reduced infertility (p=0.00) and hysteroscopy reduced dysmenorrhea (p=0.03). Hysteroscopy showed better symptom resolution in younger patients (p=0.01), whereas age did not affect laparoscopy outcomes. Both approaches showed similar effectiveness in resolving abnormal uterine bleeding, with laparoscopy excelling in infertility resolution and hysteroscopy excelling in dysmenorrhea resolution. AMAÇ: Bu çalışmanın amacı semptomatik istmosel tedavisinde laparoskopik ve histeroskopik cerrahi yaklaşımların klinik sonuçlarını değerlendirmek ve ilişkili faktörleri belirlemektir. GEREÇ VE YÖNTEMLER: Bu prospektif kohort çalışmasına transvajinal salin infüzyon sonohisterografi kullanılarak semptomatik istmosel tanısı konan 46 hasta dahil edildi. Hastalara rezidüel miyometrial kalınlık ve doğurganlık isteklerine göre laparoskopik veya histeroskopik istmoplasti uygulandı ve ardından hastalar klinik ve ultrasonografik muayenelerle takip edildi. Yirmi iki hastaya laparoskopi, yirmi dört hastaya ise histeroskopik cerrahi uygulandı. Başlangıçta, iki grup arasında ortalama yaş ve son sezaryenden bu yana geçen yıllar açısından anlamlı bir fark yoktu. Ancak histeroskopi grubunda ortalama parite ve önceki sezaryenlerin sayısı daha yüksekti (p=0,00, 0,03). En sık görülen semptomlar anormal uterin kanama, kısırlık ve dismenore idi. Başlangıçtaki ortalama rezidüel miyometrial kalınlık laparoskopi grubunda anlamlı derecede yüksekti (p=0,00) ve yalnızca laparoskopik cerrahi hastalarda anlamlı rezidüel miyometrial kalınlık artışına yol açtı (p=0,00). Her iki prosedür de anormal uterin kanamayı önemli ölçüde azalttı (p=0,00), ancak yalnızca laparoskopi kısırlığı azalttı (p=0,00) ve histeroskopi dismenoreyi azalttı (p=0,03). Histeroskopi genç hastalarda semptomlarda daha fazla düzelme sağladı (p=0,01), yaş ise laparoskopi sonuçlarını etkilemedi. SONUÇ: Her iki yaklaşım da anormal uterin kanamanın çözümünde benzer etkinlik göstermiştir; laparoskopi kısırlığın çözümünde ve histeroskopi dismenorenin çözümünde üstündür.

Analysis of factors affecting pregnancy rate after laparoscopic surgery for infertility associated with endometriosis

Zhang J et al., 2024 · Eur J Obstet Gynecol Reprod Biol · Open Access

To analyze the factors that might influence the pregnancy rate in patients with infertility related to endometriosis (EMs) after undergoing laparoscopic surgery, providing guidance for our clinical diagnostic and therapeutic decision-making. A retrospective analysis was conducted on clinical records and 1-year postoperative pregnancy outcomes of 335 patients diagnosed with endometriosis-related infertility via laparoscopic surgery, admitted to our department from January 2018 to December 2020. The overall pregnancy rate for patients with endometriosis (EMs) related infertility 1-year post-surgery was 57.3 %, with the highest pregnancy rate observed between 3 to 6 months after surgery. Factors such as Body Mass Index (BMI) (P = 0.515), presence of dysmenorrhea (P = 0.515), previous pelvic surgery (P = 0.247), type of EMs pathology (P = 0.893), and preoperative result of serum carbohydrate antigen 125 (CA125)（P = 0.615）had no statistically significant effect on postoperative pregnancy rates. The duration of infertility (P = 0.029), coexistence of adenomyosis (P = 0.042), surgery duration (P = 0.015), intraoperative blood loss (P = 0.050), preoperative result of serum anti-Müllerian hormone (AMH) (P = 0.002) and age greater than 35 (P = 0.000) significantly impacted postoperative pregnancy rates. The post-surgery pregnancy rate in patients with mild (Stage I-II) EMs was notably higher than those with moderate to severe (Stage III-IV) EMs (P = 0.009). Age (P = 0.002), EMs stage (P = 0.018), intraoperative blood loss (P = 0.010) and adenomyosis (P = 0.022) were the factors that affected the postoperative live birth rate. For patients with EMs-related infertility undergoing laparoscopic surgery, factors such as age > 35 years, infertility duration > 3 years, concurrent adenomyosis, severe EMs, surgery duration ≥ 2 h, intraoperative blood loss ≥ 50 ml, and low AMH before surgery are detrimental for the pregnancy rate within the first postoperative year. However, BMI, dysmenorrhea, past history of pelvic surgery, EMs pathology types (ovarian, peritoneal, deep infiltrating),and preoperative result of serum CA125 barely show any statistical difference in their effect on postoperative pregnancy rates. In terms of postoperative live birth rate, age > 35 years, severe EMs, intraoperative blood loss ≥ 50 ml, and adenomyosis were adverse factors.

Isthmocele and Infertility

Baldini GM et al., 2024 · J Clin Med · Open Access

Isthmocele is a gynecological condition characterized by a disruption in the uterine scar, often associated with prior cesarean sections. This anatomical anomaly can be attributed to inadequate or insufficient healing of the uterine wall following a cesarean incision. It appears that isthmocele may impact a woman's quality of life as well as her reproductive capacity. The incidence of isthmocele can range from 20% to 70% in women who have undergone a cesarean section. This review aims to sum up the current knowledge about the effect of isthmocele on fertility and the possible therapeutic strategies to achieve pregnancy. However, currently, there is not sufficiently robust evidence to indicate the need for surgical correction in all asymptomatic patients seeking fertility. In cases where surgical correction of isthmocele is deemed necessary, it is advisable to evaluate residual myometrial thickness (RMT). For patients with RMT >2.5-3 mm, hysteroscopy appears to be the technique of choice. In cases where the residual tissue is lower, recourse to laparotomic, laparoscopic, or vaginal approaches is warranted.

The optimal time for laparoscopic excision of ovarian endometrioma: a prospective randomized controlled trial

Wu Q et al., 2023 · Reprod Biol Endocrinol · Open Access

This study aimed to explore the optimal time of laparoscopic cystectomy for unilateral ovarian endometrioma patients and evaluate the influence on ovarian reserve. This prospective randomized controlled study included 88 women with unilateral ovarian endometrioma at a tertiary teaching hospital. All patients received their first identified diagnosis of ovarian endometrioma by ultrasound (> 4 cm and ≤ 10 cm) and were administered an oral contraceptive pill (OC) for one cycle before laparoscopy. They were randomly divided into two groups: laparoscopy at the late luteal phase (group LLP) (n = 44) (termination of OC for two days) and laparoscopy at the early follicular phase (group EFP) (n = 44) (day 3 after menstruation). Basic clinical characteristics were recorded. Serum Anti-Müllerian hormone (AMH) levels were measured at various times to predict ovarian reserve. Serum levels of Anti-Müllerian hormone (AMH) were measured at several time sites to predict the ovarian reserve; AMH and leukocyte esterase (LE) levels of the endometrioma wall were measured. Before surgery, serum AMH levels decreased in both groups from preoperative to one week and six months postoperatively. In contrast, the difference values of group EFP were larger than those of group LLP at postoperative one week and postoperative six months (1.87 ± 0.97 vs. 1.31 ± 0.93, P = 0.07; 1.91 ± 1.06 vs. 1.54 ± 0.93, P = 0.001). The mean rates of postoperative serum AMH decline were 37.92% and 46.34% in group EFP, significantly higher than those in group LLP (25.83% vs. 31.43%, P < 0.001). Ovarian endometrioma wall AMH of group LLP was significantly lower than that of group EFP ([22.86 ± 3.74] vs. [31.02 ± 5.23], P < 0.001). Meanwhile, ovarian endometrioma LE concentration of group LLP was significantly higher than that of group EFP ([482.83 ± 115.88] vs. [371.68 ± 84.49], P<0.001). There was also a significant inverse correlation between leukocyte esterase and AMH concentration in an ovarian endometrioma cyst wall (r=-0.564, P<0.001). CONCLUSION(S): The optimal time for laparoscopic cystectomy for patients with first identified unilateral ovarian endometrioma is the late luteal phase, which reduces ovarian tissue loss and preserves ovarian reserve effectively and safely.

The Risk of Infertility After Surgery for Benign Ovarian Cysts

Shandley LM et al., 2023 · Journal of women's health (2002) · Open Access

There is a growing body of evidence that ovarian cystectomy may negatively impact ovarian reserve. However, it is unclear whether ovarian cyst surgery puts women at risk of future infertility. This study investigates whether surgery for benign ovarian cysts is associated with long-term infertility risk. Women aged 22-45 years (n = 1,537) were invited to participate in an interview about their reproductive histories, including whether they ever had infertility or ovarian cyst surgery. Each woman reporting cyst surgery was randomly matched to a comparison woman, who was assigned an artificial surgery age equal to that of her match. Matching was repeated 1,000 times. Adjusted Cox models were fit to examine time to infertility after surgery for each match. A subset of women was invited to participate in a clinic visit to assess markers of ovarian reserve (anti-Müllerian hormone [AMH], antral follicle count). Approximately 6.1% of women reported cyst surgery. Infertility after surgery was more common for women reporting cyst surgery than those without surgery after adjusting for age, race, body mass index, cancer history, parity before assigned surgery age, history of infertility before surgery age, and endometriosis (median-adjusted hazard ratio 2.41, 95% simulation interval 1.03-6.78). The estimated geometric mean (95% confidence interval [CI]) AMH levels of those who reported a history of ovarian cyst surgery were 1.08 (95% CI: 0.57-2.05) times those of women who reported no history of surgery. Those with a history of ovarian cyst surgery were more likely to report having a history of infertility compared with age-matched women who reported no history of cyst surgery. It is possible that both ovarian surgery to remove cysts and the conditions that lead women to develop cysts requiring surgery may affect subsequent successful conception.

An Overview of Postoperative Intraabdominal Adhesions and Their Role on Female Infertility: A Narrative Review

Ghobrial S et al., 2023 · Journal of clinical medicine

Postoperative intraabdominal adhesions can occur after more than 90% of gynecologic surgeries. They not only cause chronic pelvic pain and small bowel obstruction, but are also one of the main reasons for infertility. Adhesions are not only a burden for the affected patients, but are also a burden for the healthcare system, since the treatment of adhesion-associated complications costs a considerable amount of money. The gold standard for the diagnosis of adhesions is by laparoscopy, although other methods, such as transvaginal hydro-laparoscopy, are being discussed as better alternatives. Ideally, adhesions are avoided inherently, by operating carefully and by using microsurgical principles. If this is not possible, gel barriers have been shown to be successful in reducing postoperative adhesions.

Fallopian tube recanalization for the management of infertility

Roberts A, 2023 · CVIR Endovasc · Open Access

Infertility is a world-wide problem, defined as failure to achieve pregnancy after 12 months of regular unprotected sexual intercourse. There are multiple causes for infertility involving both male and female factors. Fallopian tube occlusion is a common reason for female infertility. The initial attempts to treat proximal obstruction involved the use of a whalebone bougie positioned in the uterine cornua to dilate the proximal tube by Smith as early as 1849. Fluoroscopic fallopian tube recanalization for the treatment of infertility was first described in 1985. Since that time, there have been over 100 papers describing various methods for recanalization of occluded fallopian tubes. Fallopian tube recanalization is a minimally invasive procedure which is performed on an outpatient basis. It should be a first line therapy for patients with proximal occlusion of fallopian tubes.

Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis

Dominguez JA et al., 2023 · Ultrasound Obstet Gynecol · Open Access

The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm.

Endometriosis and Infertility: A Long-Life Approach to Preserve Reproductive Integrity

Coccia ME et al., 2022 · Int J Environ Res Public Health · Open Access

Laparoscopic surgery was originally considered the gold standard in the treatment of endometriosis-related infertility. Assisted reproductive technology (ART) was indicated as second-line treatment or in the case of male factor. The combined approach of surgery followed by ART proved to offer higher chances of pregnancy in infertile women with endometriosis. However, it was highlighted how pelvic surgery for endometriosis, especially in cases of ovarian endometriomas, could cause iatrogenic damage due to ovarian reserve loss, adhesion formation (scarring), and ischemic damage. Furthermore, in the last few years, the trend to delay the first childbirth, recent technological advances in ultrasound diagnosis, and technological progress in clinical and laboratory aspects of ART have certainly influenced the approach to infertility and endometriosis with, ART assuming a more relevant role. Management of endometriosis should take into account that the disease is chronic and involves the reproductive system. Consequently, treatment and counselling should aim to preserve the chances of pregnancy for the patient, even if it is not associated with infertility. This review will analyse the evolution of the management of infertility associated with endometriosis and propose an algorithm for treatment decision-making based on the most recent acquisitions.

Outcomes From Opportunistic Salpingectomy for Ovarian Cancer Prevention

Hanley GE et al., 2022 · JAMA network open

Opportunistic salpingectomy (OS), which is the removal of fallopian tubes during hysterectomy or instead of tubal ligation without removal of ovaries, is recommended to prevent ovarian cancer, particularly serous ovarian cancer. However, the effectiveness of OS is still undetermined. To examine observed vs expected rates of ovarian cancer among individuals who have undergone OS. This is a population-based, retrospective cohort study of all individuals in British Columbia, Canada, who underwent OS or a control surgery (hysterectomy alone or tubal ligation) between 2008 and 2017, with follow-up until December 31, 2017. Those with any gynecological cancer diagnosed before or within 6 months of their procedure were excluded. Data analysis was performed from April to August 2021. Removal of both fallopian tubes at the time of hysterectomy or instead of tubal ligation while leaving ovaries intact. An ovarian cancer diagnosis listed in the British Columbia Cancer Registry. Age-specific rates of epithelial and serous ovarian cancer in the control group were combined with the specific follow-up time in the OS group to calculate expected numbers (and 95% CIs) of ovarian cancers in the OS group. These were compared with observed numbers. Age-adjusted expected and observed numbers of breast and colorectal cancers were also examined in the OS group. There were 25 889 individuals who underwent OS (mean [SD] age, 40.2 [7.1] years; median [IQR] follow-up, 3.2 [1.6-5.1] years) and 32 080 who underwent hysterectomy alone or tubal ligation (mean [SD] age, 38.2 [7.9] years; median [IQR] follow-up, 7.3 [4.6-8.7] years). There were no serous ovarian cancers in the OS group and 5 or fewer epithelial ovarian cancers. The age-adjusted expected number was 5.27 (95% CI, 1.78-19.29) serous cancers and 8.68 (95% CI, 3.36-26.58) epithelial ovarian cancers. Age-adjusted expected vs observed numbers of breast cancers (22.1 expected vs 23 observed) and colorectal cancers (9.35 expected vs 8 observed) were not significantly different. In this cohort study, the OS group had significantly fewer serous and epithelial ovarian cancers than were expected according to the rate at which they arose in the control group. These findings suggest that OS is associated with reduced ovarian cancer risk.

Uptake and Predictors of Opportunistic Salpingectomy for Ovarian Cancer Risk Reduction in the United States

Karia PS et al., 2021 · Cancer prevention research (Philadelphia, Pa.)

Evidence suggesting that high-grade serous ovarian cancers originate in the fallopian tubes has led to the emergence of opportunistic salpingectomy (OS) as an approach to reduce ovarian-cancer risk. In the U.S., some national societies now recommend OS in place of tubal ligation for sterilization or during a benign hysterectomy in average-risk women. However, limited data exist on the dissemination of OS in clinical practice. We examined the uptake and predictors of OS in a nationwide sample of inpatient and outpatient claims (N = 48,231,235) from 2010 to 2017. Incidence rates of OS were calculated, and an interrupted time-series analysis was used to quantify changes in rates before (2010-2013) and after (2015-2017) national guideline release. Predictors of OS use were examined using Poisson regression. From 2010 to 2017, the age-adjusted incidence rate of OS for sterilization and OS during hysterectomy increased 17.8-fold [95% confidence interval (CI), 16.2-19.5] and 7.6-fold (95% CI, 5.5-10.4), respectively. The rapid increase (age-adjusted increase in quarterly rates of between 109% and 250%) coincided with the time of national guideline release. In multivariable-adjusted analyses, OS use was more common in young women and varied significantly by geographic region, rurality, family history/genetic susceptibility, surgical indication, inpatient/outpatient setting, and underlying comorbidities. Similar differences in OS uptake were noted in analyses limited to women with a family history/genetic susceptibility to breast/ovarian cancer. Our results highlight significant differences in OS uptake in both high- and average-risk women. Defining subsets of women who would benefit most from OS and identifying barriers to equitable OS uptake is needed. Opportunistic salpingectomy for ovarian-cancer risk reduction has been rapidly adopted in the U.S., with significant variation in uptake by demographic and clinical factors. Studies examining barriers to opportunistic salpingectomy access and the long-term effectiveness and potential adverse effects of opportunistic salpingectomy are needed.

Scar Tissue after a Cesarean Section—The Management of Different Complications in Pregnant Women

Stupak A et al., 2021 · IJERPH · Open Access

The definition of a cesarean scar pregnancy (CSP) is the localization of the gestational sac (GS) in the cicatrix tissue, which is created in the front wall of the uterus after a previous cesarean section (CS). The worldwide prevalence of CSP has been growing rapidly. However, there are no general recommendations regarding prophylaxis and treatment of the abnormalities of the anterior wall of the uterus discovered in a non-pregnant myometrium, or how to deal with existing cases of CSP. We present the latest knowledge, a holistic approach to the biology, histology, imaging, and management concerning post-CS scars based on our cases, which were treated in the Department of Pregnancy and Pathology of Pregnancy in the Medical University of Lublin, Poland. In our study, we present images of tissue samples of areas with a cicatrix in the uterus, and ultrasound and MRI images of CSP. We discuss the advances in the biology of the post-CS scar tissue, the prevention techniques used to repair the scar defect (niche) before the pregnancy, and the treatment of different complications of CSP, such as the rupture of the gravid uterus or the dehiscence of the myometrium.

Role of tubal surgery in the era of assisted reproductive technology: a committee opinion

Practice Committee of the American Society for Reproductive Medicine, 2021 · Fertility and Sterility

This document reviews surgical options for reparative tubal surgery and the factors that must be considered when deciding between surgical repair and in vitro fertilization. This document replaces the document of the same name, last published in 2012 (Fertil Steril 2015;103:e37-43). This document reviews surgical options for reparative tubal surgery and the factors that must be considered when deciding between surgical repair and in vitro fertilization.

Reproductive Outcomes Following Surgical Management for Isthmoceles: A Systematic Review

Harjee R et al., 2021 · J Minim Invasive Gynecol ·

To evaluate the efficacy of surgical management for isthmoceles in patients presenting with secondary infertility. Data Sources: A systematic search was performed in MEDLINE, EMBASE, and Cochrane Library databases from inception to May 2020. The search was limited to studies published in English. METHODS OF Study Selection: After the removal of duplicates, 3380 articles were screened for inclusion independently by 2 authors. These 2 authors assessed for studies which focused on women of reproductive age with a diagnosed isthmocele and secondary infertility who underwent any surgical intervention for defect repair with at least 1 of the goals being fertility restoration. TABULATION, INTEGRATION, A total of 13 studies, comprising of 1 randomized controlled trial, 6 prospective case series, and 6 retrospective case series describing 234 patients who underwent surgical management for an isthmocele and secondary infertility were included. The methodologic quality of the included studies was assessed independently by both reviewers. Next, the data extraction was performed independently and then compared to ensure no discrepancies. A total of 188 patients were treated by hysteroscopy, 36 by laparoscopy, 7 by laparotomy, and 3 through a vaginal approach. In total, 153 of the 234 patients (65.4%) achieved pregnancy across all studies within their respective study periods. Pregnancy rates in the randomized controlled trial were 21 of 28 (75%) for those treated by hysteroscopy compared with 9 of 28 (32%) for those untreated. Among the studies reporting pregnancy outcomes, 101 of 116 (87.1%) pregnancies resulted in a live birth. The incidence of adverse events was 2%, including the risk of reoperation. The results of this systematic review suggest that the surgical treatment of an isthmocele, particularly through hysteroscopy, in patients with residual myometrial thickness of at least 2.5 mm, may be effective in treating isthmocele-associated secondary infertility with a relatively low complication rate. Further high-quality studies are needed because of the small sample sizes and observational nature of most available data.

Post-caesarean Niche (Isthmocele) in Uterine Scar: An Update

Kulshrestha V et al., 2021 · J Obstet Gynaecol India · Open Access

Uterine niche is one of the emerging complications of caesarean section. With rising caesarean rates, the caesarean-related iatrogenic complications are also on the rise. These include placenta accreta, scar ectopic pregnancy and uterine niche which is a newer entity being described in the recent literature. Uterine niche, also described as uterine isthmocele, caesarean scar defect and diverticulum, is an iatrogenic defect in the myometrium at the site of previous caesarean scar due to defective tissue healing. Patients may have varied symptoms including abnormal uterine bleeding, post-menstrual spotting and infertility, though many women may be asymptomatic and diagnosed incidentally. Diagnosis is made radiologically by transvaginal sonography, saline instillation sonohysterography or magnetic resonance imaging. Occurrence of niche may be prevented by using correct surgical technique during caesarean. Patients may be managed medically; however, subfertility and persistent symptoms may require surgical correction either by hysteroscopic resection or transabdominal or transvaginal repair. This mini-review comprehensively covers the potential risk factors, clinical presentation, diagnosis and management of this increasingly encountered condition due to rising caesarean rates.

Factors affecting the success of fallopian tube recanalization in treatment of tubal obstructive infertility

Shen H et al., 2020 · J Int Med Res · Open Access

To examine potential risk factors associated with the success rate following fallopian tube recanalization (FTR) in infertile women with obstruction of the proximal fallopian tube. We retrospectively studied patients who underwent FTR for tubal obstructive infertility between January 2016 and December 2018 at the Third Affiliated Hospital of Guangzhou Medical University. FTR was performed using a catheter and guidewire system to clear tubal obstruction. Predictive factors potentially associated with the success rate were assessed by logistic regression. A total of 762 patients were included. Multivariable analysis showed that age (odds ratio [OR] = 2.38, 95% confidence interval [CI]: 1.24-4.58), infertility type (OR = 2.82, 95% CI: 1.36-6.21), history of ectopic pregnancy (OR = 7.87, 95% CI: 4.05-15.81), history of abdominal surgery (OR = 4.30, 95% CI: 2.22-8.60), history of artificial abortion curettage (OR = 4.08, 95% CI: 2.12-8.03), and duration of infertility (OR = 2.03, 95% CI: 1.06-3.85) were independently associated with postoperative tubal patency. Our findings suggest that risk factors, such as age ≥35 years, secondary infertility, duration of infertility ≥5 years, and histories of ectopic pregnancy, abdominal surgery, and artificial abortion curettage, affect the success rate of FTR. These factors may also predict surgical success in treating tubal obstructive infertility.

Conception rates after fluoroscopy-guided fallopian tubal cannulation: an alternative to in vitro fertilization for patients with tubal occlusion

Wang JW et al., 2020 · Therapeutic Advances in Reproductive Health

Previous studies show good technical success rates for fallopian tube recanalization. Scarce literature exists regarding advance techniques currently used by interventional radiologists during fallopian tube recanalization procedures. This study investigates the level of intervention and tubal patency and its association with technical success and associated pregnancy outcomes. We retrospectively evaluated fallopian tube recanalization procedures performed at a single center in a 24-year period. A total of 160 couples undergoing a basic infertility evaluation were included. Hysterosalpingography with high pressure contrast injection followed by selective contrast, guidewire catheterization at the tubal ostium, and/or microcatheter/microwire recanalization were performed. Comparisons of the tubal fertilization rate by relevant characteristics were tested for statistical significance with t tests for continuous data or with Pearson chi-square tests for categorical data. Technical success rate was 94% (319 of 341 tubes). High pressure contrast injection alone (184 of 341, 54%), selective catheterization (40%), and microcatheter/microwire (6%) interventions yielded technical success rates of 98%, 90%, and 73%, respectively. The overall rate of conception was 35% (17 of 48). Current techniques of fallopian tube recanalization offer a desirable and safe option with high technical success for patients seeking treatment for infertility due to proximal fallopian tube obstruction.

Reproductive capacity and recurrence of disease after surgery for moderate and severe endometriosis - a retrospective single center analysis

Schippert C et al., 2020 · BMC Women's Health ·

Background Endometriosis can be associated with considerable pain and sterility. After surgical excision of moderate or severe endometriosis lesions, the rate of recurrence reaches up to 67%. The objective of this retrospective study was to establish the recurrence and pregnancy rates following surgical resection of stage III/IV endometriosis lesions. Indications for operation were endometriosis symptoms, sonographic findings and/or infertility. Methods A total of 456 patients who underwent stage III/IV endometriosis surgery between 2004 and 2014 were sent a questionnaire relating to their postoperative medical treatment, pregnancies, relief of symptoms and recurrence. Responses of 206 patients (45.2%) and their clinical data were analysed for this study. Results A total of 66.5% ( N = 137) of patients had stage III disease, and 33.5% ( N = 69) had stage IV disease. The average age was 37 years (17–59). A total of 63.1% ( N = 130) of surgeries were performed by laparoscopy, 21.8% ( N = 45) were performed by laparotomy and 15% ( N = 31) were performed by conversion. Complete resection of endometriosis lesions was achieved in 90.8% of patients ( N = 187). After surgery, 48.5% ( N = 100) of the women did not receive hormonal treatment; the main reason was the desire for children in 53%. Complete or partial relief in complaints was achieved in 93.2% ( N = 192). The rate of recurrence was 21.8% ( N = 45). The statistically significant factors that was associated with a higher risk to develop recurrence was an age < 35 ( p < 0.005). After surgery, 65.8% (79/120) of patients who wished to have children became pregnant. There was a statistically significant association among a higher postoperative pregnancy rate and age < 35 ( p < 0.003) in multivariate logistic regression analysis and laparoscopic surgical access in univariate logistic regression analysis ( p < 0.01). Conclusion We assessed the high percentage of complete or partial relief of symptoms of 93.2%, the high postoperative pregnancy rate of 65.8% and the low rate of recurrence of 21.8% compared to international literature to be very encouraging for women suffering from moderate and severe endometriosis. Though laparoscopy is considered the ‘gold standard’of endometriosis surgery, laparotomy still may be indicated in patients with extensive endometriosis especially to preserve reproductive function.

Isthmocele: an overview of diagnosis and treatment

Kremer TG et al., 2019 · Rev Assoc Med Bras (1992) · Open Access

An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.

ACOG Committee Opinion No. 774: Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention

American College of Obstetricians and Gynecologists, 2019 · Obstetrics and gynecology

Opportunistic salpingectomy may offer obstetrician-gynecologists and other health care providers the opportunity to decrease the risk of ovarian cancer in their patients who are already undergoing pelvic surgery for benign disease. By performing salpingectomy when patients undergo an operation during which the fallopian tubes could be removed in addition to the primary surgical procedure (eg, hysterectomy), the risk of ovarian cancer is reduced. Although opportunistic salpingectomy offers the opportunity to significantly decrease the risk of ovarian cancer, it does not eliminate the risk of ovarian cancer entirely. Counseling women who are undergoing routine pelvic surgery about the risks and benefits of salpingectomy should include an informed consent discussion about the role of oophorectomy and bilateral salpingo-oophorectomy. Bilateral salpingo-oophorectomy that causes surgical menopause reduces the risk of ovarian cancer but may increase the risk of cardiovascular disease, cancer other than ovarian cancer, osteoporosis, cognitive impairment, and all-cause mortality. Salpingectomy at the time of hysterectomy or as a means of tubal sterilization appears to be safe and does not increase the risk of complications such as blood transfusions, readmissions, postoperative complications, infections, or fever compared with hysterectomy alone or tubal ligation. The risks and benefits of salpingectomy should be discussed with patients who desire permanent sterilization. Additionally, ovarian function does not appear to be affected by salpingectomy at the time of hysterectomy based on surrogate serum markers or response to in vitro fertilization. Plans to perform an opportunistic salpingectomy should not alter the intended route of hysterectomy. Obstetrician-gynecologists should continue to observe and practice minimally invasive techniques. This Committee Opinion has been updated to include new information on the benefit of salpingectomy for cancer reduction, the feasibility of salpingectomy during vaginal hysterectomy, and long-term follow-up of women after salpingectomy.

Isthmocele: From Risk Factors to Management

Iannone P et al., 2019 · Rev Bras Ginecol Obstet · Open Access

The aim of the present study was to perform a comprehensive review of the literature to provide a complete and clear picture of isthmocele-a hypoechoic area within the myometrium at the site of the uterine scar of a previous cesarean section-by exploring in depth every aspect of this condition. A comprehensive review of the literature was performed to identify the most relevant studies about this topic. Every aspect of isthmocele has been studied and described: pathophysiology, clinical symptoms, classification, and diagnosis. Its treatment, both medical and surgical, has also been reported according to the actual literature data. Cesarean section is the most common surgical procedure performed worldwide, and one of the consequences of this technique is isthmocele. A single and systematic classification of isthmocele is needed to improve its diagnosis and management. Further studies should be performed to better understand its pathogenesis.

The Ethics of Interstitial and Cesarean Scar Ectopic Pregnancies: Four Case Studies and a Review of the Literature

Buskmiller C, 2018 · Linacre Q ·

Catholic bioethicists have extensively addressed extrauterine tubal pregnancies, which represent the great majority of ectopic pregnancies. However, additional management options have been developed for the other 7-10 percent of ectopic pregnancies. Using two cases of interstitial pregnancy and two cases of cesarean scar pregnancy (CSP) seen at a Catholic tertiary care center, this article discusses options including expectant management, systemic methotrexate, intragestational methotrexate, intragestational potassium chloride, uterine artery embolization, dilation and curettage (D&C), vasopressin use, cornuostomy, cornual wedge resection, CSP evacuation, CSP scar excision, CSP salvage, and hysterectomy. Cornual wedge resection, vasopressin use, and CSP scar excision are morally acceptable; less clearly licit are aspiration of gestational sac contents, cornuostomy, gestational excision for CSPs, and methotrexate. Certainly illicit are any techniques leading to direct abortion such as D&Cs on live embryos or fetuses, double-balloon catheter placement, and use of potassium chloride. An ectopic pregnancy is any pregnancy outside the uterus. These are dangerous because the pregnancy can burst out of its abnormal location and cause life-threatening internal bleeding. Most are in the part of the fallopian tube outside the uterus, but there are other types, including interstitial pregnancies (located in the part of the tube tunneling through the uterine wall) and cesarean scar pregnancies (buried in the uterine scar where the cut for a C-section was made). This article lists the ways that physicians prevent women from dying from interstitial and cesarean scar pregnancies and proposes which treatments are morally acceptable.

Surgery in adenomyosis

Oliveira MAP et al., 2018 · Archives of gynecology and obstetrics

Adenomyosis is defined as the presence of endometrial glands and stroma within the myometrium. The true prevalence is unknown and has been reported to range from 1 to 70%. It has a significantly negative impact on women's quality of life, causing abnormal uterine bleeding, dysmenorrhea, and chronic pelvic pain. The definitive treatment for adenomyosis is hysterectomy, although it does not contemplate patients who wish to preserve their fertility. The aim of this paper is to discuss the latest evidence on the surgical techniques for the treatment of adenomyosis published in medical-scientific databases. A comprehensive literature search for articles published from 1996 to 2017 related to surgery for adenomyosis was made in Pubmed, Medline, the Cochrane Library, and Google Scholar, in English, by the following MeSH terms: adenomyosis, surgery, pathogenesis, dysmenorrhea and infertility. There is extensive evidence on several surgical approaches for the improvement of adenomyosis-related symptoms; however, there is no robust evidence that they are effective for infertility. The management of adenomyosis is quite complex and controversial. Complications after extensive uterine reconstruction, such as uterine rupture, should be considered and discussed with the patient. There are still limited data to support surgery effectiveness, especially for infertility, and further well-designed studies are required.

Varicocele management for infertility and pain: A systematic review

Lundy SD et al., 2018 · Arab journal of urology

Despite being first described two thousand years ago, the varicocele remains a controversial multifaceted disease process with numerous biological consequences including infertility, hypogonadism, and chronic orchidalgia. The underlying mechanisms remain poorly understood and likely include hypoxia, oxidative stress, hyperthermia, anatomical aberrations, and genetics as primary components. Despite a high prevalence amongst asymptomatic fertile men, varicoceles paradoxically also represent the most common correctable cause for male infertility. In this systematic review we discuss the rich historical aspects of the varicocele and the contemporary data regarding its clinical manifestations. We performed a systematic literature review with the goal of comparing outcomes and complication rates of each of the major surgical approaches as they relate to infertility and pain. We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-compliant systematic literature review for manuscripts focused on varicocele and its biological consequences. We identified 112 studies suitable for qualitative analysis and included 56 of these for quantitative analysis, with an emphasis on infertility and chronic pain outcomes. Taken together, the clinical work to date suggests that the highest fertility rates and the lowest complication rates are associated with the microsurgical subinguinal surgical approach to varicocelectomy. In all, 26-40% of patients undergoing varicocelectomy will successfully achieve short-term spontaneous pregnancy, and up to 90% of all patients undergoing varicocelectomy for pain will have improvement and/or resolution of their symptoms. Taken together, the data support an ongoing role for varicocelectomy in both of these clinical arenas.

Salpingectomy for Sterilization: Change in Practice in a Large Integrated Health Care System, 2011-2016

Powell CB et al., 2017 · Obstetrics and gynecology

To evaluate the utilization rate of salpingectomy for cesarean deliveries and postpartum and interval tubal sterilization procedures. This is a retrospective cohort study using the electronic medical record to identify women older than 18 years of age undergoing surgical sterilization from June 2011 to May 2016 in an integrated health care system. The primary objective is to describe the change in utilization rate of salpingectomy for tubal sterilization procedures over time and after a systemwide practice recommendation was issued in 2013. Rates of salpingectomy and tubal occlusion were calculated for each of the five 1-year intervals in the study. Secondary outcomes included blood loss, operating time, length of stay, readmission, and emergency department visits. A total of 10,741 tubal sterilization procedures were identified. There was an increase in salpingectomies from 0.4% (8/1,938; 95% CI 0.2-0.8) to 35.5% (902/2,538; 95% CI 33.7-37.4) of tubal sterilization procedures performed over the study period (test for trend, P<.001). Salpingectomy instead of tubal occlusion increased at cesarean delivery from 0.1% (1/1,141; 95% CI 0.0-0.5) to 9.2% (125/1,354; 95% CI 7.8-10.9) (test for trend, P<.001); postpartum from 0% (0/124; 95% CI 0.0-3.0) to 4.5% (9/201; 95% CI 2.4-8.3) (test for trend, P=.003); and as an interval (nonpartum) tubal sterilization procedure from 1% (7/673; 95% CI 0.5-2.1) to 78% (768/983; 95% CI 75.4-80.6) (test for trend, P<.001). Median operative minutes was increased from 52 (95% CI 51-52) to 61.5 (95% CI 57-64), from 33 (95% CI 32-34) to 50 (95% CI 35-64), and from 30 (95% CI 29-30) to 33 (95% CI 32-33), respectively, for salpingectomy compared with tubal occlusion at cesarean delivery and postpartum and interval sterilization. Median blood loss was similar for salpingectomy and tubal occlusion at cesarean delivery (660 mL; 95% CI 600-700 mL compared with 700 mL; 95% CI 680-700 mL) and interval sterilization (both 5 mL; 95% CI 5-5 mL) but was more for salpingectomy postpartum (250 mL; 95% CI 200-500 mL compared with 200 mL; 95% CI 200-200 mL). There was a significant increase in salpingectomy for sterilization from June 2011 to May 2016. In the final year of the study, salpingectomy accounted for 78% of interval laparoscopic tubal sterilization procedures and 9% of intrapartum and postpartum procedures.

Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar

Setubal A et al., 2017 · J Minim Invasive Gynecol ·

An isthmocele appears as a fluid pouchlike defect in the anterior uterine wall at the site of a prior cesarean section and ranges in prevalence from 19% to 84%, a direct relation to the increase in cesarean sections performed worldwide. Many definitions have been suggested for the dehiscence resulting from cesarean sections, and we propose standardization with a single term for all cases-isthmocele. Patients are not always symptomatic, but symptoms typically include intermittent abnormal bleeding, pain, and infertility. Pregnancy complications that result from an isthmocele include ectopic pregnancy, low implantation, and uterine rupture. Magnetic resonance imaging and transvaginal ultrasound are the gold standard imaging techniques for diagnosis. Surgical treatment of an isthmocele is still a controversial issue but should be offered to symptomatic women or the asymptomatic patient who desires future pregnancy. When surgery is the treatment choice, laparoscopy guided by hysteroscopy, hysteroscopy alone, or vaginal repair are the best options depending on the isthmocele's characteristics and surgeon expertise.

Fallopian tube catheterization in the treatment of proximal tubal obstruction: a systematic review and meta-analysis

De Silva PM et al., 2017 · Human Reproduction

What is the chance of clinical pregnancy when fallopian tube catheterization is used for proximal tubal obstruction? The pooled clinical pregnancy rate of tubal catheterization after proximal tubal obstruction is 27% (95% CI 25-30%). Restoring fallopian tube patency by performing tubal catheterization has fallen out of favour since the increased availability of IVF. Our study is the first systematic review and meta-analysis to investigate reproductive outcomes following tubal catheterization for proximal tubal obstruction. STUDY DESIGN, SIZE, We undertook a systematic review and meta-analysis of 27 observational studies consisting of 1720 patients undergoing tubal catheterization for proximal tubal obstruction, who attempted to conceive naturally after the procedure. PARTICIPANTS/MATERIALS, SETTING, Systematic literature searches were performed in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. A total of 2195 titles and abstracts were reviewed. Only studies that reported outcomes when tubal catheterization was performed with no other tubal surgery were included. Twenty-seven cohort studies matched the inclusion criteria for the meta-analysis. MAIN The meta-analysis showed a pooled clinical pregnancy rate of 27% (95% CI 25-30%) after the use of tubal catheterization for unilateral or bilateral proximal tubal obstruction (27 studies, 1556 patients). In women with bilateral obstruction (14 studies, 617 patients), the clinical pregnancy rate was 27% (95% CI 23-32%). Our meta-analysis demonstrated that the pooled cumulative clinical pregnancy rates were 22.3% (95% CI 17.8-27.8%) at 6 months, 25.8% (95% CI 21.1-31.5%) at 9 months, 26.4% (95% CI 23.0-30.2%) at 12 months, 26.0% (95% CI 22.8-29.7%) at 18 months, 27.0% (95% CI 24.0-30.5%) at 24 months, 27.9% (95% CI 24.9-31.3%) at 36 months and 28.5% (95% CI 25.5-31.8%) at 48 months. The pooled live birth rate (14 studies, 551 patients) was 22% (95% CI 18-26%). The pooled ectopic pregnancy rate (27 studies, 1556 patients) was 4% (95% CI 3-5%). The included studies scored satisfactorily on the Newcastle-Ottawa quality assessment scale. LIMITATIONS, The pooled clinical pregnancy rate after tubal catheterization was found to be almost comparable to that after IVF. However, included studies were small, non-comparative series with significant clinical heterogeneity in population characteristics, follow-up and surgical equipment, technique and experience. These findings suggest fallopian tube catheterization as an alternative strategy to IVF in patients presenting with proximal tubal obstruction. Further research should focus on comparing different surgical techniques of fallopian tube catheterization with IVF and provide cumulative reproductive outcomes over long-term follow-up. STUDY FUNDING/COMPETING INTEREST(S): No funding was required and the authors have no competing interests to declare. N/A.

Emerging Manifestations of Cesarean Scar Defect in Reproductive-aged Women

Tulandi T et al., 2016 · J Minim Invasive Gynecol ·

The objective of this study was to evaluate the prevalence of cesarean scar defects and its clinical manifestations in reproductive-aged women. We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement using keywords of "cesarean scar defect, uterine scar defect, uterine diverticulum niche, isthmocele, pouch, or sacculation" and their combination. Thirty-two trials met the inclusion criteria. Cesarean scar defects are commonly found on ultrasound examination (24%-88%). Their presence could be asymptomatic or related to postmenstrual spotting, postmenstrual bleeding, or infertility. The prevalence of this condition is related to the number of cesarean deliveries. Hysteroscopic repair of a cesarean scar defect or isthmoplasty is associated with an improvement in uterine bleeding in 59% to 100% of cases and a pregnancy rate of 77.8% to 100%. An improvement in uterine bleeding after vaginal repair occurred in 89% to 93.5% of cases. Laparoscopic repair led to uterine bleeding improvement in 86% of cases and a pregnancy rate of 86%. The association between cesarean scar defect and infertility, pelvic pain, and dysmenorrhea require more studies. Treatment of uterine scar defects should be performed after eliminating other causes of postmenstrual bleeding or infertility. Hysteroscopic isthmoplasty appears to be the most popular treatment. However, in the absence of randomized trials, the efficacy of different surgical approaches remains to be seen. Until we have concrete evidence, the treatment should be reserved for selective cases.

Ovarian Cancer: The Fallopian Tube as the Site of Origin and Opportunities for Prevention

George SH et al., 2016 · Front Oncol · Open Access

High-grade serous carcinoma (HGSC) is the most common and aggressive histotype of epithelial ovarian cancer (EOC), and it is the predominant histotype associated with hereditary breast and ovarian cancer syndrome (HBOC). Mutations in BRCA1 and BRCA2 are responsible for most of the known causes of HBOC, while mutations in mismatch repair genes and several genes of moderate penetrance are responsible for the remaining known hereditary risk. Women with a history of familial ovarian cancer or with known germline mutations in highly penetrant genes are offered the option of risk-reducing surgery that involves the removal of the ovaries and fallopian tubes (salpingo-oophorectomy). Growing evidence now supports the fallopian tube epithelia as an etiological site for the development of HGSC and consequently, salpingectomy alone is emerging as a prophylactic option. This review discusses the site of origin of EOC, the rationale for risk-reducing salpingectomy in the high-risk population, and opportunities for salpingectomy in the low-risk population.

Society of Gynecologic Oncology recommendations for the prevention of ovarian cancer

Walker JL et al., 2015 · Cancer

Mortality from ovarian cancer may be dramatically reduced with the implementation of attainable prevention strategies. The new understanding of the cells of origin and the molecular etiology of ovarian cancer warrants a strong recommendation to the public and health care providers. This document discusses potential prevention strategies, which include 1) oral contraceptive use, 2) tubal sterilization, 3) risk-reducing salpingo-oophorectomy in women at high hereditary risk of breast and ovarian cancer, 4) genetic counseling and testing for women with ovarian cancer and other high-risk families, and 5) salpingectomy after childbearing is complete (at the time of elective pelvic surgeries, at the time of hysterectomy, and as an alternative to tubal ligation). The Society of Gynecologic Oncology has determined that recent scientific breakthroughs warrant a new summary of the progress toward the prevention of ovarian cancer. This review is intended to emphasize the importance of the fallopian tubes as a potential source of high-grade serous cancer in women with and without known genetic mutations in addition to the use of oral contraceptive pills to reduce the risk of ovarian cancer.

New diagnostic criteria and operative strategy for cesarean scar syndrome: Endoscopic repair for secondary infertility caused by cesarean scar defect

Tanimura S et al., 2015 · J Obstet Gynaecol Res ·

The aim of the present study was to assess the efficacy of endoscopic repair for secondary infertility caused by post-cesarean scar defect (PCSD). Our investigation focused on the validity of new diagnostic criteria and selection methods. MATERIAL AND The subjects were 22 women with secondary infertility due to PCSD with retention of bloody fluid in the uterine cavity. Women with a residual myometrial thickness of ≥ 2.5 mm and an anteflexed or straight uterus underwent hysteroscopic surgery, while all others underwent laparoscopic repair. Hysteroscopic surgery involved resection and coagulation of scarred areas, whereas laparoscopic surgery involved removal of scarred areas combined with hysteroscopy, followed by resuturing. Fourteen of the 22 women (63.6%) who were followed up for ≥ 1 year after surgery achieved pregnancy. Pregnancies occurred in all four women (100%) who underwent hysteroscopic surgery and in 10 of the 18 women (55.6%) who underwent laparoscopic surgery. Three out of four women who underwent hysteroscopic surgery had term deliveries. Among the women who underwent laparoscopic surgery, five had term deliveries. No cases of uterine rupture were experienced, and the delivery method was cesarean section in all cases. We propose that infertility associated with PCSD, cesarean scar syndrome, is caused by the retention of bloody fluid in the uterine cavity and scarring. Endoscopic treatment, such as hysteroscopy or laparoscopy, was effective for cesarean scar syndrome.

Role of tubal surgery in the era of assisted reproductive technology: a committee opinion

Practice Committee of the American Society for Reproductive Medicine, 2015 · Fertil Steril ·

This document reviews surgical options for achieving patency in obstructed fallopian tubes and the factors that must be considered when deciding between surgical repair and IVF. This document replaces the document of the same name, last published in 2012 (Fertil Steril 2012;97:539–45).

The laparoscopic management of endometriosis in patients with pelvic pain

Yeung PP Jr, 2014 · Obstet Gynecol Clin North Am ·

Endometriosis, an underdiagnosed and undertreated condition, affects 1 in 10 women and is associated with pain and infertility. Preoperative evaluation should include testing and management of other causes of pelvic pain. Ultrasonography can aid in surgical planning. Hormonal suppression improves symptoms, but should not be used to diagnose endometriosis, and is not shown to be effective in preventing disease recurrence nor in improving fertility. The goal of surgical management should be optimal removal or treatment of disease and should include measures for adhesion prevention. Rates of recurrence of endometriosis depend on the surgical completeness of removing the disease.

Acceptability of prophylactic salpingectomy with delayed oophorectomy as risk-reducing surgery among BRCA mutation carriers

Holman LL et al., 2014 · Gynecol Oncol · Open Access

Given the emerging evidence for the fimbria as the site of origin for many serous carcinomas in BRCA mutation carriers, consideration is being given in studying prophylactic salpingectomy with delayed oophorectomy (PSDO) as a risk-reducing surgery. We aimed to determine the interest in a study of PSDO among these women. We evaluated the results of an online survey conducted by Facing Our Risk of Cancer Empowered (FORCE), a patient advocacy group, from October 2010 to August 2012. Premenopausal BRCA mutation carriers with no history of ovarian cancer or prior bilateral salpingo-oophorectomy (BSO) were included. Of the 204 women meeting inclusion criteria, median age was 35 years, 92.5% were white, 25.7% were Jewish, and 16.7% had a history of breast cancer. Overall, 34.3% reported interest in a study of salpingectomy, 35.3% were unsure, and 30.4% were not interested in the study. Women noted the possibility of lowering ovarian cancer risk without menopause as a compelling reason to participate (83.8%). Reasons for not participating in a salpingectomy study included surgical complications (46.6%), potential ovarian damage (42.2%), planning BSO soon (32.4%), and surgical costs (32.8%). Acceptable study risks included the need for two surgeries (77.2%), possibility of not lowering ovarian cancer risk (68%), and disruption of ovarian blood supply (66.5%). One-third of BRCA mutation carriers indicated definite interest in a PSDO study. Potential study risks were acceptable to most women. These findings suggest that patient accrual for a clinical trial of prophylactic salpingectomy with delayed oophorectomy is possible.

Fallopian tube catheterization

Thurmond AS, 2013 · Seminars in Interventional Radiology · Open Access

Fallopian tube catheterization is used for treatment of infertility caused by proximal tubal occlusion, and has replaced surgical treatment for this condition. More recently, fallopian tube catheterization has been used for tubal sterilization. Interventional radiologists tested numerous methods for tubal occlusion using the rabbit as an animal model. As a result, a tubal device has recently been Food and Drug Administration approved for permanent sterilization using hysteroscopic guidance; it can also be placed fluoroscopically by fallopian tube catheterization as an "off-label" procedure. This is a 5-year continuation and update on a procedure that has been done by interventional radiologists for 25 years; history of the development of fallopian tube catheterization in women has been published in detail in this journal. Highlighted in this article will be description of the basic components needed for fallopian tube catheterization.

The definition, aetiology, presentation, diagnosis and management of previous caesarean scar defects

Allornuvor GF et al., 2013 · J Obstet Gynaecol ·

Caesarean sections are the most commonly performed surgical procedures involving the uterus in fertile women. Typically, this surgery involves a transverse incision in the anterior lower uterine segment. The incidence of caesarean sections is on the increase worldwide, and consequently, the complications associated with them are becoming more common. One such complication that is gaining more attention is previous lower uterine segment caesarean scar defect (PCSD). In this review, we sought to explore the definition, aetiology, presentation, diagnosis and management of PCSD.

Selective salpingography and tubal catheterization in infertile women

El Fekih C et al., 2012 · Tunis Med ·

Use of selective salpingography (SS) and fallopian tube catheterization (TC) has revolutionized the diagnosis and treatment of proximal tubal infertility. To evaluate results of women treated for proximal tubal obstruction by selective salpingography and tubal catherization. Selective salpingography was performed in women with proximal bilateral tubal obstructions. Follow-up ranged from 4 to 12 months. twelve patients had been shown to have bilateral proximal obstruction of the fallopian tube. After SS/TC, patency was achieved in 8 cases. Spontaneous conceptions occurred in 4 women. SS and TC should be used more widely because it is simple and effective in case of proximal tubal blockage.

Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility

Florio P et al., 2012 · Curr Opin Obstet Gynecol ·

To review the treatments of the cesarean-induced isthmocele in restoring infertility, associated techniques, and the risks of complications associated with their use. Recent Findings: Isthmocele is a reservoir-like pouch defect on the anterior wall of the uterine isthmus located at the site of a previous cesarean delivery scar. The flow of menstrual blood through the cervix may be slowed by the presence of isthmocele, as the blood may accumulate in the niche because of the presence of fibrotic tissue, causing pelvic pain in the suprapubic area. Moreover, persistence of the menstrual blood after menstruation in the cervix may negatively influence the mucus quality and sperm quality, obstruct sperm transport through the cervical canal, interfere with embryo implantation, leading to secondary infertility. The removal of the local inflamed tissue may be performed by laparoscopic, combined laparoscopic-vaginal, or vaginal surgery, and operative hysteroscopy, a minimally invasive approach to improve symptoms and restore fertility. Isthmocele occurs after cesarean section, a common method of delivery and one of the most frequent surgical procedures, so that its upward incidence appears likely to continue in the near future. Because of its minimal invasiveness, resectoscopy may be the better choice for treatment, yielding good therapeutic results.

Laparoscopic management of endometriosis: comprehensive review of best evidence

Yeung PP Jr et al., 2009 · J Minim Invasive Gynecol ·

To provide a comprehensive review of the best evidence available in the laparoscopic management of endometriosis for pain and/or fertility and to provide practical recommendations based on this information. Review article of randomized controlled trials. Women with endometriosis. A systematic search was performed of the Cochrane Library and MEDLINE database for randomized controlled trials relating only to laparoscopic management of endometriosis. The information from 7 Cochrane review articles and 35 original randomized trials is presented in a clinically relevant question-and-answer format. Awareness of endometriosis as a disease with substantial morbidity is vitally important. Laparoscopic treatment of endometriosis is beneficial for reducing pain and improving fertility. Laparoscopic presacral neurectomy, but not laparoscopic uterosacral nerve ablation, is a useful adjunct to conservative surgery for endometriosis in patients with a midline component of pain. Preoperative hormonal suppression with gonadotropin-receptor hormone analogue may be helpful in decreasing endometriosis disease scores. Postoperative hormonal suppression with either a gonadotropin-receptor hormone analogue or progestin (including the levonorgestrel intrauterine system) may be helpful in reducing pain and increasing time to recurrence of symptoms. Excisional cystectomy is the preferred method to treat endometrial cysts for both pain and fertility and may be aided by the use of mesna and initial circular excision. An absorbable adhesion barrier (Interceed), 4% icodextrin solution (Adept), and a viscoelastic gel (Oxiplex/AP, FzioMed, Inc., San Luis Obispd, CA; not available in the United States) are safe and effective products to help prevent adhesions in laparoscopic surgery to treat endometriosis.

Preoperative periumbilical ultrasound-guided saline infusion (PUGSI) as a tool in predicting obliterating subumbilical adhesions in laparoscopy

Cho J et al., 2008 · Fertil Steril ·

To report the novel technique of periumbilical ultrasound-guided saline infusion (PUGSI). Prospective study of two noninvasive diagnostic tests to detect obliterating subumbilical adhesions. Tertiary care center. PATIENT(S): One hundred fifty patients were included in the study. Patients without risk factors for adhesions were used as a control group (n = 38), whereas the study group had risk factors for intra-abdominal adhesions (n = 112). INTERVENTION(S): Preoperative examination with the visceral slide and the PUGSI. MAIN OUTCOME MEASURE(S): The presence of obliterating subumbilical adhesions in the high-risk patient and the ability of the PUGSI to detect them preoperatively. RESULT(S): There were no obliterating umbilical adhesions in the control group. The prevalence of obliterating umbilical adhesions in the risk group was 3.6%. The visceral slide test had an accuracy of 96.4%, a sensitivity of 50%, and a specificity of 98.1%, with a negative predictive value of 98.1% and a positive predictive value of 50%. The PUGSI test was able to detect all cases of obliterating subumbilical adhesions, demonstrating sensitivity and specificity of 100%. CONCLUSION(S): The PUGSI test has excellent negative and positive predictive values and is useful in determining patients who have obliterating subumbilical adhesions. Use of both tests preoperatively appears to be helpful in identifying patients at risk for visceral injury during laparoscopic surgery.

Proximal tubal disease: the place for tubal cannulation

Das S et al., 2007 · Reproductive BioMedicine Online

Tubal disease is the cause of subfertility in approximately 30% of women, and 10-25% of these are due to proximal tubal obstruction. False-positive diagnosis of proximal tubal obstruction can be as high as 50%. A decrease in expertise in tubal microsurgery has resulted largely from the use of IVF as the treatment option for most causes of infertility and more specifically for tubal factor infertility. Selective salpingography and tubal cannulation have a unique role in the management of tubal infertility and should be offered to selected candidates prior to IVF. Tubal cannulation can be used effectively to restore patency in a proportion of cases of proximal tubal obstruction thus avoiding the need for expensive assisted reproductive techniques. This review examines the evidence supporting the effectiveness of tubal cannulation and aims to enhance awareness of the procedure as an option for the management of female subfertility secondary to isolated proximal tubal obstruction.

An economic evaluation of laparoscopic ovarian diathermy versus gonadotrophin therapy for women with clomiphene citrate-resistant polycystic ovarian syndrome

Farquhar CM, 2005 · Curr Opin Obstet Gynecol ·

Women with polycystic ovarian syndrome are typically anovulatory and require ovulation induction. Ovarian wedge resection was the first treatment for anovulation but was eventually abandoned because of the increased risk of postsurgical adhesions and as medical ovulation induction with clomiphene and gonadotrophins was introduced. However, with the advent of laparoscopy, there has been a return to surgical approaches. The potential advantages of laparoscopic surgery include avoidance of hyperstimulation and the lowered costs make ovarian surgery an attractive alternative to gonadotrophins. Recent Findings: Clinical trials in New Zealand and the Netherlands have compared costs of laparoscopic ovarian drilling with gonadotrophins. The total cost of treatment in the Netherlands study for the ovarian drilling group was euro 4664 and for the gonadotrophins group was euro 5418. Without the cost of monitoring and the diagnostic laparoscopy then the difference was euro 2110 in favour of ovarian drilling. It was estimated that the cost per term pregnancy would be euro 14,489 for gonadotrophin and euro 11,301 for ovarian drilling (22% lower). The higher rates of multiple pregnancy in the gonadotrophin group were considered to be responsible for the increased costs. In the New Zealand trial the costs of a live birth were one-third lower in the group that underwent laparoscopic ovarian diathermy compared with those women who received gonadotrophins (NZ$19,640 and 29,836, respectively). Treating women with clomiphene-resistant polycystic ovarian syndrome with laparoscopic ovarian diathermy results in reduced direct and indirect costs. The reduction in multiple pregnancies makes the alternative of surgery particularly attractive.

Chapter 62: What is Surgical NaProTECHNOLOGY?

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Surgical NaProTECHNOLOGY is defined as a cooperative surgical discipline that corrects reproductive pathology identified through CrMS monitoring and targeted diagnostic workup, employing microsurgical and laser techniques that maximize tissue preservation and minimize adhesion formation. The philosophical and technical distinctions from conventional gynecologic surgery are established, emphasizing restorative intent and anatomical precision as core principles.

Chapter 68: Laparoscopic Laser Vaporization of Endometrial Implants

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

CO2 laser vaporization technique for peritoneal and superficial ovarian endometriotic implants is described in detail, covering power density settings, spot size, vaporization depth control, and recognition of adequate treatment endpoints. Complete destruction of all visible implants, facilitated by the near-contact survey, is necessary to achieve durable symptom relief and improvement in fertility outcomes.

Chapter 42: Endometriosis and Effects on Fertility

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Endometriosis impairs fertility through direct mechanical distortion of pelvic anatomy, peritoneal inflammatory mediators, and hormonal micro-environment alterations that reduce implantation potential, making thorough surgical excision critical to restoring fertility rather than bypassing it. The PEARS classification system, used in NaProTECHNOLOGY surgical practice, enables standardized documentation of endometriotic disease extent and correlates operative findings with postoperative reproductive outcomes.

Chapter 65: Atlas of Findings in Diagnostic Laparoscopy

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

A photographic atlas documents the intraoperative appearance of endometriosis, adhesions, polycystic ovarian morphology, tubal pathology, and uterine anomalies as encountered during near-contact laparoscopy. Standardized visual reference supports consistent surgical classification, intraoperative decision-making, and communication of findings across the NaProTECHNOLOGY surgical team.

Chapter 66: Selective Hysterosalpingography and Transcervical Catheterization of the Fallopian Tubes

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

Selective hysterosalpingography combined with transcervical fallopian tube catheterization allows both precise diagnosis and non-surgical correction of proximal tubal occlusion, distinguishing true anatomical obstruction from tubal spasm or mucous plugging. In NaProTECHNOLOGY practice, this minimally invasive approach restores tubal patency without laparotomy, preserving natural conception potential in appropriately selected patients.

Chapter 70: PEARS: Peritoneal and Ovarian Endometriosis

Hilgers TW, 2004 · The Medical and Surgical Practice of NaProTECHNOLOGY ·

The PEARS (Pelvic Endoscopic Adhesion-Related Surgery) procedure for peritoneal and ovarian endometriosis combines near-contact laser vaporization, adhesiolysis, and ovarian cystectomy under strict anti-adhesion protocols to achieve comprehensive disease eradication while preserving ovarian reserve. Outcomes data demonstrate superior fertility and pain resolution compared to incomplete surgical approaches, establishing PEARS as the operative standard within NaProTECHNOLOGY.

Success of laparoscopic ovarian wedge resection is related to obesity, lipid profile, and insulin levels

Duleba AJ et al., 2003 · Fertil Steril ·

To evaluate the effects of laparoscopic ovarian wedge resection on hormonal and metabolic parameters of polycystic ovary syndrome (PCOS) and to compare profiles of women who achieved pregnancy with those who did not. Prospective study. University hospital. PATIENT(S): Thirty-three women with PCOS. INTERVENTION(S): Laparoscopic ovarian wedge resection using harmonic scalpel. MAIN OUTCOME MEASURE(S): Pregnancy; levels of testosterone, DHEAS, gonadotropins, sex hormone-binding globulin (SHBG), and glucose and insulin during 2-hour glucose tolerance test; lipid profile; body mass index; and waist-to-hip ratio. RESULT(S): Twenty-two women (67%) achieved clinical pregnancy within the mean of 4.9 months after surgery. Baseline parameters of women who became pregnant differed from those who did not: those who became pregnant were less obese, had lower levels of total cholesterol, low-density lipoprotein, and triglycerides; higher levels of SHBG; lower levels of fasting insulin; lower insulin area under the curve; and higher insulin sensitivity index. Subjects not pregnant by 12 weeks after surgery underwent repeat endocrine and metabolic evaluations. In these women, wedge resection was followed by declines in testosterone, LH, and insulin sensitivity index. Wedge resection had no significant effect on SHBG, DHEAS, or lipid profile. CONCLUSION(S): Laparoscopic wedge resections are associated with the highest pregnancy rates among less obese subjects with favorable lipid profiles and lower insulin. In this study, the postoperative decline of serum testosterone and LH is not attributable to improvement of insulin sensitivity.

Peritoneal defects and the development of endometriosis in relation to the timing of endoscopic surgery during the menstrual cycle

Schweppe KW et al., 2002 · Fertil Steril ·

In vitro studies demonstrated that implantation on membranes (peritoneum, amniotic membranes) can take place if there are defects on the surface of the membranes. If these mechanisms play a role for the development of endometriosis in vivo, then patients with surgical treatment of peritoneal endometriosis in the luteal phase must have a high recurrence rate. Retrospective analysis of operation charts and follow-up data. Department of gynecology, in a hospital-based endometriosis treatment center. PATIENT(S): Two hundred twenty premenopausal women. INTERVENTION(S): Laparoscopic treatment for peritoneal endometriosis, stage I and II by revised American Society for Reproductive Medicine guidelines. MAIN OUTCOME MEASURE(S): During the follow-up period of 2 years, symptoms and gynecological and sonographic findings were documented. In case of suspected recurrence a repeat laparoscopy with biopsy was performed to prove the recurrent endometriosis macroscopically and histologically. RESULT(S): The total recurrence rate after 2 years was 9.6%. The recurrence rate of group III (15%) was twice as high as those of group I (7%) and group II (8%), as indicated by subjective complaints, clinical findings, macroscopy, and histology; no differences were found between groups I and II. CONCLUSION(S): Endoscopic surgery for the treatment of peritoneal endometriosis should not be performed in the luteal phase.

Laparoscopy in the "normal" infertile patient: a question revisited

Corson SL et al., 2000 · J Am Assoc Gynecol Laparosc ·

To determine the prevalence of reproductive pathology in a group of infertile women thought to be at low risk for altered pelvic anatomy. Retrospective chart review and follow-up (Canadian Task Force classification II-2). Academic-affiliated, private reproductive endocrinology practice. One hundred infertile women. Diagnostic and/or therapeutic laparoscopy. MAIN Of 100 patients with a negative reproductive work-up up to the point of laparoscopy, 68 had pathology of reproductive intrinsic tubal disease 24, peritubal adhesive disease 34, and endometriosis 43, some in combination. Laparoscopy was especially helpful in establishing treatment protocols for older women, who were referred for assisted reproductive techniques earlier than otherwise might have been the case. Women conceived after hormone therapy and after operative intervention. Although the hysterosalpingogram was read as normal in all women, tubal disease was diagnosed laparoscopically, independent of endometriosis, in 27 patients, with 2 having complete obstruction. Endometriosis stage I-II was found in 22 patients, stage III in 13, and stage IV in 6. Even in women thought to be at low risk for significant pelvic pathology affecting reproduction, the yield was high. Although some pregnancies were achieved after operative intervention, frequently laparoscopy was helpful in making a decision to go to assisted reproductive technology, particularly when infertility had been of long duration and in older women. Frequently the degree of pathology was such that a full operating suite was necessary to provide adequate instrumentation and anesthesia for operative intervention, which would not have been the case with office laparoscopy.

Diagnostic laparoscopy in infertile women with normal hysterosalpingograms

al-Badawi IA et al., 1999 · J Reprod Med ·

To assess the value of laparoscopy in infertile women with normal hysterosalpingograms, with and without risk factors suggesting pelvic disease. We retrospectively reviewed 1,022 consecutive charts from a tertiary infertility practice. In 265 women, laparoscopies were performed after normal hysterosalpingograms. Laparoscopies were normal in 136 (51%) women, whereas 129 (49%) had one or more abnormal laparoscopic findings, including minimal or mild endometriosis (n = 85), moderate or severe endometriosis (n = 11), adnexal adhesions (n = 27), subserosal myomas (n = 17), ovarian neoplasms (n = 5), distal phimosis (n = 1) and salpingitis isthmica nodosa (n = 1). Only 7% of cases had findings that might require standard operative laparoscopy or laparotomy, although not all were causally related to infertility. A history of dysmenorrhea or dyspareunia increased the likelihood of detecting endometriosis from 41% to 64% and 69%, respectively. The presence of both symptoms increased the likelihood to 83%. In the presence of a normal hysterosalpingogram, laparoscopy identified other pelvic disease in about half of patients. Because most abnormalities were mild, this knowledge can be used to plan a micro-laparoscopic approach for many women, reserving traditional or operative laparoscopy for women with an abnormal hysterosalpingogram or extensive disease following micro-laparoscopy. Alternately, knowledge of the nature and severity of the expected laparoscopic findings might lead to bypassing laparoscopy in favor of assisted reproduction when the perceived benefit of surgical intervention is small.

Revised American Society for Reproductive Medicine classification of endometriosis: 1996

American Society for Reproductive Medicine, 1997 · Fertil Steril ·

Salpingitis isthmica nodosa: results of transcervical fluoroscopic catheter recanalization

Thurmond AS et al., 1995 · Fertil Steril ·

To investigate the role of transcervical tubal catheterization in diagnosis and treatment of proximal tubal obstruction associated with salpingitis isthmica nodosa. Retrospective case study. University hospital and outpatient radiology practice. Fifty-two women with proximal tubal obstruction associated with salpingitis isthmica nodosa. Selective salpingography and catheter recanalization using fluoroscopic guidance. The number of tubes visualized to the fimbria as a percentage of the tubes with proximal tubal obstruction on the initial hysterosalpingogram was determined as a measure of diagnostic efficacy. To evaluate the treatment potential of catheter recanalization, the patients were grouped according to tubal status at the conclusion of the procedure and subsequent pregnancies were evaluated. Forty-seven of 65 tubes (72%) with proximal tubal obstruction were recanalized successfully. Among the 19 women who were able to conceive only via a recanalized salpingitis isthmica nodosa tube, there were 6 live births (32%) and two tubal pregnancies (10%). Selective salpingography allows complete tubal diagnosis in almost three fourths of patients with proximal tubal obstruction and salpingitis isthmica nodosa. The radiographic diagnosis of salpingitis isthmica nodosa may be pressure dependent. Intrauterine pregnancies occur via recanalized salpingitis isthmica nodosa tubes, therefore catheter recanalization may be attempted before tubal microsurgery or IVF in patients with proximal tubal obstruction and associated salpingitis isthmica nodosa.

Salpingoscopic findings in women with occlusive and nonocclusive salpingitis isthmica nodosa

Urman B et al., 1994 · Fertil Steril ·

To characterize ampullary endosalpingeal findings in women with occlusive or nonocclusive salpingitis isthmica nodosa. Prospective case study. Obstetrics and Gynecology Department of a University Hospital. Twenty women (38 tubes) with occlusive or nonocclusive salpingitis isthmica nodosa were studied. Salpingoscopy was performed during diagnostic laparoscopy in 20 women (38 tubes) with hysterosalpingographic evidence of salpingitis isthmica nodosa. Salpingoscopic findings were recorded and the patients were managed accordingly. Of the 38 tubes 10 appeared radiographically and laparoscopically normal. Two tubes were occluded distally. Of the 26 tubes with occlusive or nonocclusive salpingitis isthmica nodosa, 5 (19.2%) showed varying degrees of endosalpingeal abnormality. Patients with abnormal salpingoscopy were regarded as having bipolar tubal disease and were referred for assisted conception. The remaining patients were scheduled for microsurgical tubal reconstruction. One in five patients with proximal tubal disease may have ampullary endosalpingeal damage of varying degrees. However, the significance of this finding in relation to subsequent management strategies and fertility outcome is yet to be characterized.

Laparoscopic excision of endometriosis with 3-mm scissors: comparison of operating times between sharp excision and electro-excision

Redwine DB, 1993 · The Journal of the American Association of Gynecologic Laparoscopists

To determine if laparoscopic excision of endometriosis by electrosurgery is more rapid than by sharp dissection, a retrospective comparative study was made of operative times for the two procedures. Median operating times for laparoscopic electro-excision of endometriosis were 26% to 49% faster than excision by sharp dissection. A chi2 analysis of the frequency counts of surgical intervals, and disease stage revealed this difference to be statistically significant and not due to acquired experience or differences in extent of disease in the two groups. The reduction in operating time achieved with monopolar electro-excision seems primarily associated with a more rapid cutting action with simultaneous coagulation of bleeders.

Salpingitis isthmica nodosa: a review of the literature, discussion of clinical significance, and consideration of patient management

Jenkins CS et al., 1993 · Fertil Steril ·

To examine and discuss the pathology, diagnosis, incidence, and patient profile of salpingitis isthmica nodosa and to question its natural history, propose management strategies, and identify areas of promising research. Over 50 studies were reviewed, evaluated, and compared to offer the clinician a foundation on which to generate treatment plans. Salpingitis isthmica nodosa is diagnosed by the pathological presence of isthmic diverticula and may be suggested by characteristic changes on hysterosalpingogram. Its incidence in healthy, fertile women ranges from 0.6% to 11%, but it is significantly more common in the setting of ectopic pregnancy and infertility. There are no studies, retrospective or prospective, that clearly dictate appropriate therapy. Given its progressive nature and probable deleterious effects on fertility, we propose that microtubal surgery be the definitive treatment for qualified women who have salpingitis isthmica nodosa.

Endocrine changes and clinical outcome after laparoscopic ovarian resection in women with polycystic ovaries

Campo S et al., 1993 · Hum Reprod ·

Ovarian laparoscopic resection was applied to 23 sterile patients affected with polycystic ovarian disease (PCOD) resistant to different pharmacological treatments, in order to induce ovulation. After resection, 56% of the patients had spontaneous ovulatory cycles and 13 pregnancies arose. Ten of the pregnancies were spontaneous and three followed treatment with clomiphene. Hormone changes were assessed in 15 patients, including five with spontaneous menstruation but without ovulation and five with persistent amenorrhoea for 3 months after resection. A significant decrease in both androstenedione and testosterone levels occurred in all patients. These decreases were not related to the clinical results of resection. Luteinizing hormone (LH) did not vary greatly in any group after resection. Mean values and mean pulsatility of follicle stimulating hormone (FSH) increased significantly only in pregnant patients or those with spontaneous ovulatory cycles. The results of gonadotrophin-releasing hormone (GnRH) assays did not change after resection. The mechanisms involved in the resumption of cyclic function of the hypophyseal-ovarian axis after resection are discussed briefly.

Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease

Redwine DB, 1991 · Fertility and sterility

To determine the long-term outcome after laparoscopic excision of endometriosis. This longitudinal unmatched study evaluated surgical outcome using follow-up questionnaires and evaluation of reoperations with results presented in life table format. Surgery was performed by a private practitioner at a referral center. All 359 patients undergoing laparoscopic excision of endometriosis between December 12, 1980, and March 31, 1990, were studied. Endometriosis, including deeply invasive disease, was completely excised laparoscopically using 3-mm scissors and graspers. Adjunctive medical therapy was not used. Extent of disease present at reoperation and quarterly rates of reoperation and recurrent/persistent disease are used as indicators of efficacy of surgery. Interval rates of reoperation and recurrence/persistence of disease and extent or invasiveness of disease when found at reoperation did not increase with the passage of time after surgery. The maximum cumulative rate of recurrent or persistent disease was 19%, achieved in the 5th postoperative year. Laparoscopic excision of endometriosis results in a low rate of minimal persistent/recurrent disease. The natural history of endometriosis after surgery suggests a rather static nature of the disease.

Fallopian tube catheterization and recanalization under ultrasonic observation: a simplified technique to evaluate tubal patency and open proximally obstructed tubes

Lisse K et al., 1991 · Fertil Steril ·

To test a sonoscopic technique developed for transvaginal catheterization and recanalization of the fallopian tube. In a feasibility study, catheterization was performed with the use of laparoscopic control. Patients with bilateral proximal tubal obstruction underwent fallopian tube recanalization under ultrasonic observation. This study represents patients evaluated for primary or secondary infertility at Humboldt University Hospital. PATIENTS, Proximal tubal obstruction had been diagnosed on previous hysterosalpingogram and with laparoscopy. None. Tubal patency was assessed by hydrotubation under ultrasonic observation. Transvaginal catheterization was successful in 31 (91.2%) of the 34 tubes. In 19 patients with proximal tubal obstruction, patency of both or at least one tube was achieved in 16 (84.2%) women. Five (31.6%) of 16 patients successfully recanalized were found to have an intrauterine pregnancy at a 6-month follow-up interval. This catheterization technique should be investigated for possible use in diagnostic schedule early in the evaluation of the infertile patient. Also, the transvaginal recanalization of proximally obstructed tubes calls into question the application of microsurgical treatment of a selected group of patients.

Transcervical selective salpingography: a diagnostic and therapeutic approach to cases of proximal tubal injection failure

Capitanio GL et al., 1991 · Fertil Steril ·

Evaluation of selective salpingography for diagnosis and treatment of tubal injection failure during hysterosalpingography (HSG). Prospective study. Obstetrics and Gynecology Department, University of Genoa (Italy)--tertiary care. One hundred eighty infertile women with unilateral or bilateral proximal tubal injection failure during HSG were submitted to the procedure. Under fluoroscopy, a 4.5-F nylon catheter (3-F tip) was inserted into the ostium with or without the aid of a J-shaped, coaxial, angiographic guide wire, and 2 to 3 mL of contrast medium were injected. The procedure lasts 20 to 30 sec/tube. Of 155 tubal ostia, 145 (94.2%) were catheterized. Of the 146 catheterized tubes, 110 (75%) were rendered patent. Of the others, 21 (14.3%) presented hydrosalpinx or distal obstructions, and isthmic obstruction was present in 5 (3.4%). Patency of at least one tube was achieved in 82 (81.2%) of the 101 catheterized women; 8 conceived spontaneously and 11 after gamete intrafallopian transfer to the recanalized tube. During HSG, selective salpinography can be performed when proximal injection failure is observed to determine its cause or to restore patency.

Selective salpingography and fallopian tube recanalization

Thurmond AS, 1991 · AJR Am J Roentgenol ·

Obstruction of the uterine (proximal) end of the fallopian tube is noted on up to 20% of hysterosalpingograms and has a variety of underlying causes. Definitive diagnosis and treatment in the past have required laparoscopy or laparotomy with tubal resection. Selective salpingography and fallopian tube recanalization with fluoroscopically guided catheters has emerged as an improved method both for diagnosis and treatment in these patients. Technical success rates for overcoming the obstruction and visualizing distal tubal anatomy range from 76% to 95%. Pregnancy rates after the procedure vary depending on the patient populations studied; however, early results indicate a greater than 50% intrauterine pregnancy rate by 1 year. The rate of ectopic pregnancy is approximately 10% and that of early tubal reocclusion is less than 30%. Selective salpingography and fallopian tube recanalization is recommended as the first intervention in patients with obstruction of the proximal fallopian tube.

Proximal fallopian tube occlusion: diagnosis and treatment with transcervical fallopian tube catheterization

Kumpe DA et al., 1990 · Radiology ·

Transcervical fallopian tube catheterization (TFTC) was performed in 22 infertile patients with bilateral fallopian tube obstruction and a mean duration of infertility of 3.3 years. A high prevalence of previous ectopic pregnancy (n = 8, 36%), tubal ligation and/or reconstruction (n = 5, 23%), spontaneous or therapeutic abortion (n = 6, 27%), and previous intrauterine device use (n = 14, 64%) was noted. The authors successfully catheterized 40 (98%) of 41 tubes without serious complication and visualized the distal tube in 36 (88%) of 41 tubes. Free spill in at least one tube was seen in 17 (77%) of 22 patients. Nineteen patients had a history of previous laparoscopy or laparotomy for tubal disease, in 16 of whom laparoscopic results were available for review. Retrospectively, in 15 (94%) of 16 patients all clinically relevant abnormalities would have been detected by means of TFTC alone. Five patients conceived, three with intrauterine and two with ectopic pregnancies. Patients with intrauterine pregnancies had normal-appearing tubes after TFTC, while those with ectopic pregnancies had residual tubal abnormalities after recanalization. TFTC is a safe, accurate diagnostic procedure that provides more information than hysterosalpingography and, in most cases, as much or more information about the fallopian tubes than laparoscopy.

Selective osteal salpingography and transvaginal catheter dilatation in the diagnosis and treatment of fallopian tube obstruction

Lang EK et al., 1990 · AJR Am J Roentgenol ·

Selective salpingography and transvaginal catheter dilatation were performed in 157 women with infertility to diagnose, localize, and classify obstructive diseases of the fallopian tubes and to correct obstruction of the proximal (uterine-end) tube. In 61 (39%) of the patients, the selective salpingograms showed patent tubes despite the fact that two previous hysterosalpingograms showed obstruction of the proximal (uterine-end) tube. Transvaginal catheter dilatation successfully recanalized the proximal portion of the tubes in 79 (82%) of 96 patients with obstructed tubes. In 18 of 25 with successful transvaginal catheter dilatation and 6-month follow-up salpingography, the tubes remained patent. Coexisting disease of the distal (ovarian-end) tubes was diagnosed in 29 (18%) of the patients. Pregnancy was achieved in 11 of the 157 patients (six in whom obstructions were corrected by transvaginal catheter dilatation and five in whom selective salpingograms showed patent tubes). There were no complications due to the procedure. The excellent diagnostic and therapeutic yield, lack of complications, and low cost justify the use of these percutaneous techniques to investigate female infertility and to treat obstruction of the uterine end of the fallopian tube.

Premenstrual syndrome improvement after laser ablation of the endometrium for menorrhagia

Lefler HT Jr, 1989 · J Reprod Med ·

Laser ablation of the endometrium was performed on 18 patients for menorrhagia. The patients were evaluated for the premenstrual syndrome (PMS) preoperatively and again at three and six months postoperatively. An improvement in both the severity and duration of PMS symptoms was noted postoperatively, and the reduction in menstrual bleeding was correlated with the reduction in PMS symptoms.

The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, müllerian anomalies and intrauterine adhesions

American Fertility Society, 1988 · Fertil Steril ·

Histology of proximal tubal occlusion

Sulak PJ et al., 1987 · Fertil Steril ·

From 1979 to 1985, 18 patients who were found to have proximal tubal obstruction by hysterosalpingography and laparoscopic chromopertubation underwent resection of the obstructed tubal segment and reimplantation or microanastomosis. Resected tubal segments were studied histologically, and in 11 of the 18 cases no tubal occlusion could be demonstrated. A variety of histologic abnormalities were noted, however, including six cases in which the tubal lumen contained an amorphous material of unknown etiology, often appearing to form a cast of the tube. Such "plugs," which the authors believe to be previously unreported, have no clearly established clinical significance at present. However, if they cause tubal occlusion, this would explain several previously published findings, and would also have implications for therapy.

Salpingoscopy versus hysterosalpingography in hydrosalpinges

Puttemans P et al., 1987 · Hum Reprod ·

A technique of translaparoscopic salpingoscopy is utilized to evaluate the ampullary segment of the Fallopian tube in patients suffering from infertility. Comparison of this technique with hysterosalpingography in a series of 32 patients with hydrosalpinges demonstrates its superiority in the evaluation of the tubal mucosa. This new diagnostic approach allows a more accurate selection of patients for either microsurgical repair, in-vitro fertilization (IVF) or gamete intra-Fallopian transfer (GIFT).

Treatment of cervical ectropion by cryosurgery: effect on cervical mucus characteristics

Baram A et al., 1985 · Fertil Steril ·

Eighteen women with cervical ectropion and 12 women with ectropion and vaginal discharge were treated by cryosurgery. Evaluation of the cervical mucus characteristics by cervical score and in vitro penetration test was performed before treatment and 2 months later. In the group with ectropion only (group A) the total cervical score was 5.7 +/- 0.4 and 11.9 +/- 0.06 (P less than 0.001) (mean +/- standard error) before treatment and 2 months later, respectively. In the group with ectropion and vaginal discharge (group B) the total cervical score before and after cryosurgery was 3.8 +/- 0.4 and 11.8 +/- 0.1 (P less than 0.001), respectively. In vitro penetration tests in group A before and after treatment were 0.72 +/- 0.1 and 2.9 +/- 0.08 (P less than 0.001), respectively. In group B, in vitro penetration tests before and after cryosurgery were 0.25 +/- 0.1 and 2.8 +/- 0.1 (P less than 0.001), respectively. It appears that cryosurgery improves the cervical mucus characteristics. It is recommended that infertile patients with hostile cervical mucus and ectropion will be treated by cryosurgery.

Laparoscopic examination of the normal infertile woman

Wood GP, 1983 · Obstet Gynecol ·

It is generally accepted that laparoscopy should be performed if a woman's basic infertility evaluation reveals no abnormalities. Although it has been shown that a significant number of these patients have unsuspected pelvic pathology that can be detected by laparoscopy, there is concern about the real benefit of this procedure, ie, does the laparoscopic examination truly lead to more pregnancies than otherwise expected? Presented is a review of a series of 50 female patients whose basic infertility evaluation had failed to reveal any abnormalities. Laparoscopy revealed significant pelvic pathology in 28 cases; of the 16 who had appropriate therapy, eight became pregnant.

Long-term clinical effects of ovarian wedge resection in polycystic ovarian syndrome

Hjortrup A et al., 1983 · Acta Obstet Gynecol Scand ·

Twenty-nine consecutive patients with polycystic ovary (PCO) syndrome (defined as hirsutism plus oligomenorrhea or secondary amenorrhea, and excluding Cushing's syndrome, an androgen-secreting adrenal or ovarian tumor or adrenocortical hyperplasia) were treated with ovarian wedge resection leaving normal-sized ovaries. Long-term follow-up from 2.3-9.5 years (mean 5.7 years) showed that 26 of 29 patients (90%) had established normal menstrual cycles. Fertility and normal pregnancies were achieved in all 10 patients (100%) with normal postoperative menstrual cycles who desired to conceive, but not in the 3 patients with remaining postoperative oligomenorrhea. Eight of 9 patients who were obese preoperatively and who had normal postoperative menstrual cycles showed a major weight loss after wedge resection. In contrast, none of the preoperatively obese patients, who remained oligomenorrheic after surgery, lost weight. Hirsutism was not cured by wedge resection. It is concluded that ovarian wedge resection should still be considered useful in patients with PCO.

The conservative surgical treatment of endometriosis: evaluation of pregnancy success with respect to the extent of disease as categorized using contemporary classification systems

Rock JA et al., 1981 · Fertil Steril ·

A homogeneous group of 214 infertile women with endometriosis treated at the Johns Hopkins Hospital from 1960 to 1979 received conservative surgery as the sole therapeutic modality. Among this group, 115 patients (54%) conceived following surgery; of these conceptions, 109 resulted in a living child. Among 49 patients with secondary infertility, the spontaneous abortion rate was reduced from 49% to 20% after conservative surgery (P less than or equal to 0.01). Three contemporary classification systems were utilized to categorize patients according to the sites and amount of endometriosis at the time of conservative surgery. Those systems suggested by Buttram (Fertil Steril 30:240, 1978) and by Kistner and coauthors (Fertil Steril 28:108, 1977) revealed differences among fecundability rates among the different categories (P less than or equal to 0.01); however, the system suggested by The American Fertility Society (AFS) (Fertil Steril 32:633, 1979) revealed significant differences only if categories were combined (mild plus moderate versus severe plus extensive, P less than or equal to 0.05). Nevertheless, the AFS system revealed that pregnancy success was significantly reduced if an ovarian endometrioma was greater than 3 cm or had ruptured (P less than or equal to 0.01).

The effect of ovarian wedge resection and incision on circulating gonadotropin in patients with polycystic ovarian disease

Tanaka T et al., 1978 · Int J Fertil ·

Wedge resection (WR) was performed in 12 women with polycystic ovarian disease (PCOD), and Incision was done in 4 PCOD patients without any resection of ovarian tissue. Serum LH, FSH, estradiol-17beta (E2), progesterone, and urinary 17 ketosteroid (17KS) were measured serially before and after surgery. Neither WR nor Incision had any effect on FSH levels. Serum LH levels which had been hypergonadotropic preoperatively, became markedly lower 7--14 days after surgery in 12 wedge-resected and 2 incised patients. Within 7 days after WR there was a significant fall of E2 and a decrease of 17KS. In addition to those hormonal changes observed after WR, BBT charts turned out to be diphasic after the oral administration of dydrogesterone (Duphaston) in 12 out of 17 PCOD patients. The present data suggest that the reduction of the serum LH, induced by an interaction between the ovarian steroidogenesis and the suprapituitary mechanisms, might be involved in the occurrence of ovulation after WR in PCOD patients.

Noxytiolin and peritoneal adhesion formation

Gilmore OJ et al., 1976 · Br J Surg ·

Clinical and experimental studies have suggested that intraperitoneal noxytiolin prevents adhesion formation. A reliable experimental animal model was therefore established and the effect of noxytiolin on adhesion formation was evaluated in a controlled trial using 80 rats. All 40 rats given Ringer solution developed adhesions, whereas in 7 out of 40 given noxytiolin no adhesions were found (P less than 0-02). Noxytiolin reduced both the total and the mean number of adhesions formed (P less than 0-2) and their mean length of attachment (P less than 0-05). The anti-adhesive effect of noxytiolin may be due to its anticoagulant, cytotoxic or antibacterial properties.

Stein-Leventhal syndrome

Halbe HW et al., 1972 · Am J Obstet Gynecol ·

Infertility surgery for men

Human Fertilisation & Embryology Authority, · Human Fertilisation & Embryology Authority

Some men who don’t produce sperm naturally, or who have a blockage preventing sperm from coming out, can have surgery to increase their chances of conceiving. This includes men with fertility issues following chemotherapy and men who want to try and reverse a vasectomy. Surgical sperm extraction and vasectomy reversal are two common procedures.

AAPLOG Endometriosis & Surgery 101

Whittaker NM,

To discuss candidates for surgery, tools & techniques for endometriosis surgical treatment, as well as adhesion prevention measures

Surgery for Male Infertility

NYU Langone Health, · NYU Langone Health

Urologists at NYU Langone sometimes recommend surgery to manage conditions that cause problems with sperm production in men with infertility. Surgical options include varicocelectomy, varicocele embolization, transurethral ejaculatory duct resection, vasectomy reversal, and microsurgical testicular sperm extraction.

Surgical Treatment for Male Infertility

Society for the Study of Male Reproduction et al., · Society for the Study of Male Reproduction, Inc.

Surgical treatment for male infertility may include varicocelectomy, microsurgical reconstruction, vasectomy reversal, and epididymovasostomy. These procedures can help improve sperm movement, concentration, and structure, and can be effective in reversing blockages caused by vasectomy or other conditions. It is essential to find an experienced microsurgeon to perform these procedures. The Society for the Study of Male Reproduction provides resources and information for patients and physicians, including a directory of male infertility specialists and a patient education forum.